Surgery Genitourinary
Content
GENITOURINARY
Hernia: Abnormal protrusion of a viscus or part of a viscus through a defect either in the containing wall or within the cavity of the viscus. Involves anterior & posterior muscle layers of the abdomen, diaphragm, and walls of the pelvis. Can be either external or internal. External Hernia: Common, present as abnormal lump. (Inguinal most common in males, femoral more common in females) Richter’s Hernia: Part of the circumference of bowel trapped within hernial sac (Does not result in intestinal obstruction due to non-occlusion of lumen of bowel) Littre’s Hernia: A small bulge in the small intestine present at birth (Meckel’s diverticulum) lies within hernia sac, most common in femoral or inguinal hernia. Maydl’s Hernia: Hernial sac contains two loops of intestine that may become obstructed or strangulated. Not recognized unless hernia contents are inspected. Predisposing Factors: • Congenital (i.e. present at birth) • Acquired • Increased Intra-abdominal pressure (Coughing/vomiting/ascites) Complications: Irreducibility (least serious): Adhesions between sac and its contents Fibrosis leading to narrowing of neck of the sac Sudden increase in IAP that causes permanent displacement of the sac • • • • Obstruction: neck is sufficiently narrow to occlude the lumen of the intestine Nearly always irreducible and may become strangulated Urgent Presents with intestinal obstruction (abdominal colic, vomiting, constipation, abdominal distension) Strangulation (most serious): Compression at the hernial orifice cuts off blood supply Lymphatic and venous obstructed, leading to oedema and venous congestion Serious complication if intestine is involved Erythema of the overlying skin is a late sign
• • • •
• Immediate operation needed • • • • Reducible Hernia: Easy come, easy go Irreducible Hernia: hard to be reduced Incarcerated Hernia: Retented and confined hernia Strangulated Hernia: Causes enteric necrosis Inguinal Hernia: Most common hernia, frequent in men. Etiology: • Inguinal canal passes through the abdominal wall between the deep (internal) and superficial (external) inguinal rings • The canal is a site of weakness and therefore potential herniation Indirect Inguinal Hernia: • The neck of the sac is situated lateral to the inferior epigastric artery • Sac accompanies the spermatic cord along the inguinal canal towards the scrotum • Sac lies in front of the cord, enclosed by the coverings of the cord Causes: • failure of the processus vaginalis to form the ligamentum vaginale • loss of integrity of the inguinal canal Direct Inguinal Hernia: Rare in females, doesn’t occur in children, more common on right side after appendicectomy. Protrudes directly through posterior wall of inguinal canal, medial to the inferior epigastric artery. • • • • • • • • • • Causes: Main reason is weakness of the inguinal canal Herniation occurs at Hesselbach’s triangle Neck of a DIH is usually larger than the body and so strangulation is rare Rarely reaches a large size or approaches the scrotum Features: Inguinal discomfort Pain Severe pain suggests obstruction or strangulation. Lump usually obvious, often precipitated by increasing IAP, reduce completely with rest and lying down. The patient initially is examined standing to demonstrate the lump and possible cough impulse
• Then lying down to allow the hernia to be reduced • • • • • • • • • • Difference between IIH & DIH: IIH protrudes along the line of the inguinal canal towards the scrotum or labia DIH appears as a diffuse bulge at the medial end of the inguinal canal IIH is prevented from appearing by applying pressure over the deep inguinal ring (which lies just above the midpoint of the inguinal ligament) DIH protrudes through the posterior wall of the inguinal canal medial to the deep ring. IIH is controlled by pressure in the deep ring DIH appears medial to the examiner’s two fingers Accurate distinction may be impossible because of variation of the deep inguinal ring IIH are more likely to develop complications If the pulse lies laterally, it is indirect inguinal hernia. If the pulse lies medially, it is considered as direct inguinal hernia.
Treatment: • Inguinal hernias are best treated surgically • May under general, regional or local infiltration anaesthesia • • • • • Principles of Operation: Any correctable aggravating factors be identified and treated In infants and young adults, repair usually be limited to high ligation Eliminate the hernia sac, reconstruct the inguinal floor Bilateral repair usually discouraged; Laparoscopic repair can be done with low risk
Traditional Repair (Herniorrhaphy): • Repair posterior wall of the inguinal canal • Repair the external oblique aponeurosis • Strong non-absorbable sutures are used IMPORTANT: Bassini, Halsted, & McVay have higher chances of recurrence & is more painful, while Shouldice has lower chances of recurrence but isn’t popular. TensionFree Repair is MOST POPULAR NOW. Bassini Repair: • Conjoint tendon is sutured onto the inguinal ligament • Spermatic cord remains under the external oblique aponeurosis Halsted Repair: • Resemble Bassini repair
• Except place the external oblique aponeurosis beneath the cord McVay Repair: • Resemble Bassini repair • Except suture the conjoined tendon onto the Cooper’s ligament Shouldice Repair (GOLD STANDARD FOR HERNIORRHAPHY): • Divide the transversalis fascia • deep inguinal ring is closed around the cord • conjoined tendon and internal oblique muscle are approximated in layers to the inguinal ligament Advantages & Disadvantages: • cheap, easy to perform • recurrence rate, pain, discomfort, ect. Hernioplasty Process: • Insertion of a prosthetic mesh to cover and support posterior wall of the inguinal canal • The mesh is cut to size and is then sutured to the posterior wall behind the cord • Alternatively, the mesh can be placed deep in the defect of the posterior wall Most widely used Techniques include: • Plug--insert the plug into the internal ring, with or without sheet of mesh • Lichtenstein--use mesh to cover the entire inguinal floor • Both • • • • • • • • Laparoscopic Hernia Repair: performed under general anaesthesia, using either a transperitoneal or extraperitoneal approach not appropriate for large or irreducuble hernias Advantages of laparoscopic hernia repair include reduced post-operative pain and earlier return to work Disadvantages include increased risk of femoral nerve and spermatic cord damage, risk of developing intraperitoneal adhesions with the transperitoneal procedure, and greater cost and duration of the operation Includes Total ExtraPeritoneal approach (TEP)/ TransAbdominal PrePeritoneal approach (TAPP)/ IntraPeritoneal Onlay Mesh (IPOM) TEP is preferable to TAPP because of its lower complication and recurrence rates, the “best repair.” TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy.
• • • • •
Benefits of Biological Mesh: Safe Strong Least of infection and rejection Resists adhesions Fewer complications than synthetics
DIAGNOSIS OF URINARY DISEASES Classification of Pain:
• • • • Renal Pain: Located in the ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib. Caused by acute distention of the renal capsule, generally from inflammation or obstruction. May be associated with gastrointestinal symptoms; Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12.
Ureteral Pain: • Usually acute and secondary to obstruction. • Hyperperistalsis and spasm Vesical Pain: • Inflammatory conditions of the bladder usually produce suprapubic discomfort • Acute urinary retention • Overdistention and inflammation Prostatic Pain: • Usually secondary to inflammation with secondary edema and distention of the prostatic capsule; • Poor localization Penile Pain: • Usually secondary to inflammation in the bladder or urethra, pain at urethral meatus. Testicular Pain:
• Primary pain arises from within the scrotum, secondary to acute epididymitis • Chronic scrotal pain is usually related to noninflammatory conditions • The pain is generally characterized as a dull, heavy sensation that does not radiate. HEMATURIA: ＞3 red cell per High-power field IMPORTANT: Urinary infection is the most common cause of hematuria. • • • • Classification: Hematuria gross or microscopic At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)? Pain association If the patient is passing clots, do the clots have a specific shape?
Differences: • Initial hematuria usually arises from the urethra; • Total hematuria is most common and indicates that the bleeding is most likely coming from the bladder or upper urinary tracts. • Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra. Association with Pain: • Pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots. • Acute urinary infection (most common cause of hematuria) Shape of Clots: • The presence of wormlike clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract; • Hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise and demands immediate urologic examination. • • • • • Differential Diagnosis Evaluation of Hematuria: Glomerular Hematuria. IgA Nephropathy (Berger's Disease), the most common cause of glomerular hematuria, accounting for about 30% of cases . Nonglomerular Hematuria The urinalysis in nonglomerular hematuria is distinguished from that of glomerular hematuria by the presence of circular erythrocytes and the absence of erythrocyte casts.
ABNORMALITY OF VOIDING VOLUME • • • • • • • • Classification: Polyuria: Greater than 2000ml per day with normal drinking (diabetes, diabetes insipidus and polyuria stage of renal failure, etc.); Oliguria: Less than 400ml per day with normal drinking; Anuria: Less than 100ml per day (prerenal, renal and postrenal anuria) Prerenal anuria: Inadequate of renal irrigation; Renal anuria: Dysfuntion of urinary production; Postrenal anuria: Obstruction of urinary tract. SYMPTOMS: Irritative: • Frequency; • Urgency; • Dysuriea • • • • • Obstructive: Decreased force of urination; Urinary hesitancy (delayed start of urination) Intermittency (occasionally stop during urination) Postvoid dribbling; Straining INCONTINENCE • • • • • • • • • • Classification: Continuous Incontinence; Stress Incontinence; Urgency Incontinence; Overflow Urinary Incontinence; Enuresis; SEXUAL DYSFUNCTION: Loss of Libido; Impotence; Failure to Ejaculate; Absence of Orgasm; Premature Ejaculation;
• Hematospermia; Diagnosis: Physical Examination Urinalysis (Midstream urine sample preferred) Abdominal Plain Radiography Intravenous Urography (Requires normal renal function, For Renal Parenchyma and evaluating Hematuria/Urolithiasis) CT Ultrasound MRI
• • • • • • •
Invasive Examination: • Cystoscope/Ureteroscope/Nephronscope • Retrograde Urography/ Urethrography (Performed by cystoscope/urethral meatus GENITOURINARY TRAUMA • • • • • • • • • • • • • • • General Considerations: 10% of E.R. trauma visits Often associated with multi-system trauma Subtle presentations, easily overlooked Diseased GU organs susceptible to injury Evaluation (Primary Survey): Airway with Cervical spine protection Breathing high-flow oxygen Circulation control of external bleeding, 2 large-bore IVsDisability assessment of neurologic status Disability assessment of neurologic status Exposure / Environment undress / temperature control Renal Trauma: General Considerations: • Most commonly injured GU organ • Often in association with multi-system organ injury
• －must be suspected in individuals with chest,abodominal or back injury • Blunt >80% • Penetrating <20% Types of Trauma: • • • • • • • • • • • • • • • • • • • • Blunt: Most common form of renal trauma Types of injury Motor vehicle accidents Falls from heights Assaults Mechanisms of injury High velocity impact (contusion / hematoma / laceration) Deceleration injury (RA thrombosis / RV disruption / avulsion of renal pedicle) Penetrating: Uncommon form of renal trauma Types of injury Gunshot wounds Stab wounds Mechanisms of injury Direct shearing force through renal tissue Presentation: Hematuria (gross or microscopic) Microscopic = 5 RBCs/HPF May be absent Shock (hypotension, tachycardia, oliguria) Flank bruising/ palpable mass Flank pain/tenderness
Diagnosis: • CT • • • • Classification (Using AAST): grade I : contusion or non enlarging subcapsular haematoma, but no laceration ; grade II : superfical laceration < 1cm depth and does not involve the collecting system ; non expanding perirenal haematoma grade III : laceration > 1cm, without extension into the renal pelvis or collecting system and with no evidence of urine extravasation grade IV : laceration extends to renal pelvis or urinary extravasation.
• grade V : shattered kidney ; devascularisation of kidney due to hilar injury. Non-operative management: Hemodynamic stable patient with an injury well staged by CT can usually be managed with nonoperative 98% of renal injuries can be managed nonoperatively bed rest increased fluid intake antibiotids close observation Grade IV &V injuries more often require surgical exploration Surgical Indications: Absolute: • Persistent renal bleeding with hemodynamic instability • Expanding perirenal hematoma • Pulsatile perirenal hematoma • • • • • Relative: Penetrating injuries Extensive urine extravasation Grade 5 injury Non-viable tissue (>20%) Arterial injury (main or segmental)
• • • • • • •
Methods: • partial nephrectomy • nephrectomy (normal contralateral kidney) • • • • • • • • • IMPORTANT: TOTAL NEPHRECTOMY ONLY IF: the vasculature is completely avulsed . the kidney is ischemic . the kidney is the site of life threatening uncontrolable hemorrhage. Principles of Renal Reconstruction: Complete renal exposure Debridement of non-viable tissue Hemostasis Suture ligature (Gelfoam, Surgicel/Argon beam coagulation) Water-tight closure of collecting system
• Approximation/coverage of parenchymal defect Complications: Early: • Urine extravastion (most common) • Hemorrhage, shock • Urinoma formation • • • • Late: Infection Abscesses Loss of renal function Hypertension Bladder Trauma: • • • • • General Conisderations: Relatively uncommon Often in association with multi-system organ injury Significant mortality rate (10-20%) Have high index of suspicion of urethral disruption injury Bladder more susceptible to injury when full Types of Trauma: • • • • • • Blunt: Most common type of bladder injury Usually motor vehicle accidents 2/3 contusions, 1/3 ruptures Associated with pelvic # 10-25% of pelvic #’s have associated bladder injury 85-90% of bladder injuries have associated pelvic #
PENETRATING • Less common • Often associated with major organ injuries IATROGENIC • Open or laparoscopic pelvic surgery • Gynecologic, vascular, urologic or general surgery • SPONTANEOUS RUPTURE
• Underlying pathology • Cancer, obstruction, XRT, TB, sensory neurologic deficit • • • • • • • • Presentation: Gross hematuria (the classic finding) 95% blunt injuries have gross hematuria Inability to void Abdominal pain Abdominal bruising Pelvic mass Peritoneal signs Shock Classification: Extraperitoneal injury : Most common treatment by catheter drainage Surgery when : Bone fragment into bladder Open pelvic Fracture Rectal perforation Poor catheter drainage
• • • • • •
Intraperitoneal injury : • Rapid raising intraperitoneal pressure cause of the bladder burst, dome • Surgery treatment Complications: Intraperitoneal • Urinary frequency • Shock • Peritonitis Extraperitoneal • Shock • Pelvic abscess Ureteral Trauma: Etiology: • External trauma very rare • <4% of penetrating trauma • <1% of blunt trauma
• Look for concomitant visceral injuries (SB, LB, K, B) • Usually surgical trauma (Gynecologic, vascular, urologic or general surgery/Open/Laparoscopic/Ureteroscopy) Presentation: • At time of external trauma • If unrecognized intra-op, then:Low grade fever, ileus, Flank pain, Fluid drainage from incision, drain sites • Hematuria may be absent • • • • • • • • • • • • • • • • • • • Diagnostic Tests: Methylene blue IV or renal pelvic injection For suspected intra-op ureteral injury Allows localization of injury IVP CT scan Ureteropyelogram Retrograde Antegrade Surgical Indications: Ureteric injury during operation The most common cause; surgical trauma during hysterectomy or other pelvic surgery Preoperative catheterization of the ureters makes them easier to identify during surgery Injuries discovered at the time of surgery should be repaired immediately Injury not recognized at the time of operation Unilateral injury :3 possibilities No symptoms :ligate ureter lead to silent atrophy kidney Loin pain and fever :pyonephrosis Urinary fistula :through the abdominal or vaginal wound, tempolary nephrostomies Bilateral injury (Anuria) Complications: Early: • Hydronephrosis • Urinoma
• Infection Late: • Stricture • Loss of renal function • Stone formation Testis Trauma: • • • • • • General Considerations: Usually due to blunt trauma Sports, fights 1-2% of gunshot wounds Pain, scrotal hematoma, bruising Physical exam often difficult due to pain and degree of swelling U/S most useful investigation (To determine if ruptured)(May miss tunical fracture)
Management: • Most cases are low grade injuries (contusions or hematomas) and are therefore managed non-operatively (Ice, analgesics, bedrest/activity restrictions • Indications to operate:Rupture of tunica albugineaExpanding or large hematocele Intratesticular hematoma • Surgery: Repair vs. orchidectomy URINARY TRACT INFECTION IMPORTANT DEFINITIONS: Upper urinary tract infection: infection occurs in kidney, pelvis and ureter • Lower urinary tract infection: infection occurs in bladder and urethra • Cystitis: infection occurs mainly in bladder, and usually with urethritis • Urethritis: infection occurs mainly in urethra • • • • Classification: Upper urinary tract infection or lower urinary tract infenction Pyelonephritis vs cystitis vs urethritis first infection vs recurrent infection Complicated vs uncomplicated
Diagnosis: • Location of infection: upper or lower • Pathogen: urine culture
• Any anatomic abnormalities in urinary tract Pyelonpehritis: • • • • • • Symptoms: Fever Flank pain Tenderness on flank Dysuria Urinary urgency Urinary frequency Cystitis: • • • • • • • Symptoms: Dysuria Urinary urgency Urinary frequency with Hematuria suprapubic pain foul-smelling urine No fever Complicated vs Uncomplicated: Patients with uncomplicated cystitis • occasionally occurred annually • No history of abnormalities in urinary tract • 80% UTI resulted in with E Coli • • • • • • • • Management: Hydration-drinking more water No need to do urine cultrue Antibiotics 1. TMP-SMX(trimethoprim-sulfamethoxazole) for 3 days 2. fluoroquinolone (Ciprofloxacin, Levofloxacin) for 3 days If urine analysis is still not negative after that 1. urine culture 2. antibiotics based on urine culture
Patients with complicated cystitis • recurrence in recent three months • history of abnormalities in urinary tract
• • • • • • • • • •
history with multiple antibiotics previously pathogen diagnosis should be based on urine culture Management: Urine culture for recurrent UTI Ultrasound screening for any abnormalities of urinary tract CT scan or IVU for any abnormal finding from ultrasound screening Uroflowmetry with residual urine for patient with difficult voiding Control Diabetes Mellitus Antibiotics in initial stage: in first week 1. TMP-SMX(trimethoprim-sulfamethoxazole) 2. fluoroquinolone (Ciprofloxacin, Levofloxacin) Antibiotics should be based on urine culture The effective antibiotics should be maintained for over two week Prostatitis:
• • • • • • • •
Classification: Acute bacterial prostatitis-category 1 Acute urinary symptoms with bacteremia • Chronic bacterial prostatitis-category 2 Chronic urinary symptoms with bacteria in prostate • Nonbacterial prostatitis-category 3 Chronic urinary symptoms without bacteria in prostate • asymptomatic prostatitis-category 4 inflammation in prostrate without symptoms and bacteria in prostate Category 1:
• • • •
Symptoms: UTI symptoms: dysuria, urgency, frequency, nocturia, perineal, low back • Urinary hesitancy, fever, chills, malaise • Enlarged, tender prostate on DRE • Minimize rectal exams for fear of urosepsis Treatment:
pain
• • • • •
Category 1: Bed resting, antipyretics, hydration urine culture for antibiotic sensitivities Suprapubic drainage if patient were in urinary retention Treat with broad spectrum antibiotics parenteraly until sensitivities are back Continuing oral proper antibiotics for 4 weeks after controlling acute symptoms to eradicate bacteria in prostate
Category 2: Symptoms: • Episodes of dysuria, frequency, pelvic, perineal pain, usually without fever • Prostate secretion test culture should be done for further treatment • • • • • • • • Treatment: Antibiotics option E coli present in 80% of cases, Klebsiella, Pseudomonas aeruginosa, Proteus less common TMP-SMX and fluoroquinolones orally are the first line for 4~6 weeks Option could be based on culture sensitivities when it is available other adjuvant therapy α-blocker: could relieve urinary symptoms analgesics: could relieve chronic pain cernilton: pollen agents Orchitis: Classification: • • • • • • • • • • • Acute bacterial orchitis Secondary to UTI Secondary to STD Nonbacterial infectious orchitis Viral Fungal Parasitic Rickettsial Noninfectious orchitis Idiopathic Traumatic Autoimmune Chronic orchitis Chronic orchialgia Clinical Manifestation: Symptoms: • Unilateral testis pain and swollen • Fever ( acute cases) • abdominal discomfort, nausea, and vomiting
• The skin of the involved hemiscrotum is erythematous and edematous • Most cause of bacteria is E.Coli and Pseudomonas Treatment: Systemic support bed rest scrotal support Hydration Antipyretics anti-inflammatory agents analgesics Antibiotic therapy Same principle as acute or chronic bacterial prostatitis Paranteral antibiotics for acute cases Oral antibiotics for 4~6 weeks Fluoroquinolone should be the first line of option GENITOURINARY TUBERCULOSIS • • • • • • • • • • • • • • • Definition: Tuberculosis involving kidney, ureter, bladder and male genitals It should be taken as a part of systemic Tuberculosis Cause is Tubercle bacillus Clinical Manifestation: Frequency, urgency and dysuria Hematuria Pyuria Lumbago Systemic Symptoms Diagnosis: Urine Rt Acid Fast Staining Urine Culture US KUB+IVP CT & MRI
• • • • • • • • •
• Cystoscopy • • • • • Treatment: Systemic Therapy Chemotherapy Surgical Treatment (Nephrectomy/Reconstructive Surgery) Postoperative Chemotherapy Bladder Contracture (Only considered after cure of TB) Male Genitals TB: Clinical Manifestation: • Non-tenderness nodules in prostate • Non-tender swelling of vas deferens • Fistula formation of scrotum Symptoms & Treatment: SAME FOR TYPICAL GU TB URINARY TRACT OBSTRUCTION • • • • • Classification: Congenital or Acquired Mechanical or Dynamical Upper urinary tract or Lower urinary tract Disorders of the tract or other systems Upper Urinary (Kidney/Ureter/Multifactoral) or Lower Urinary (Prostate/Urethra) Tract Congenital UPJ Obstruction: Causes: • Congenital (Aperistaltic segment of ureter) • Acquired (Compression from bands) Results of UTO: • Lowered GFR • Lowered Renal Blood Flow Complications: • Renal Parenchymal Atrophy (Renal Failure) • Urosepsis (Bacteria in circulatory system)
Hydronephrosis: Blockage in urine drainage from pelvis, leading to elevated pelvic pressure and dilated calyces, resulting in renal parenchyma atrophy (Renal failure). Severity depends on: • Duration • Degree (Complete or Incomplete) • Site • • • • Symptoms: Congenital (Asymptomatic to abdominal mass) Acquired (Symptoms of primary disease) Complete Obstruction (Renal Colic) Intermittent (Persistent and complete obstruction)
Diagnosis: • Confirmation • Severity & Renal Function Clinical Findings: Laboratory: • Infection (Urinalysis/Leukocytosis) • Renal Function (Azotemia/Electrolyte Imbalance) • • • • • • Imaging: Sonography (Thin renal parenchyma) KUB Excretory Urography (Reveals entire cause unless severely impaired renal function) Retrograde Uropathy (Percutaneous Urography in case of failure) CT & MRI (Differentiate from solid tumors) Isotope Scan
Treatment: • Treating primary disease • Relief of obstruction (JJ-Drainage/Nephrostomy) • Nephrectomy (ONLY in Irreversible kidney damage) BENIGN PROSTATIC HYPERPLASIA Definition: Hyperplasia of prostatic epithelial cells that leads to formation of large nodules in periurethral region, why may eventually cause complete obstruction of the urethra.
General factors: • Mostly occurs in peripheral zone • Most common benign tumor in men • • • • • • • • Symptoms: Men > 50yrs. Prostate size has poor correlation with symptoms (Middle lobe causes severe symptoms) Severity based on obstruction, progressive speed, and associated infection Urination frequency, urgency, nocturia & dysuria Symptoms of Complications: UTI Odynuria Bladder stone Hematuria Renal failure (Hydronephrosis)
IPSS: International-Prostate Symptom Score, used to determine severity. • Mild: 0-7 • Moderate: 8-19 • Severe: 20-35 IMPORTANT: BPH determined by Digital Rectal Examination (DRE). • Tone of anal sphincter • Prostate size & consistency • Nodules • • • • • • Diagnosis: DRE Uroflowmetry Urodynamic Study Ultrasonography Prostate Specific Antigen (Marker for Prostate Cancer) Cystoscopes (When Transitional Cell Carcinoma suspected)
Treatment: • Watching waiting • Medical therapy (Alpha-blockers/Finasteride) • Phytotherapy (Plant extracts) Surgical Treatment: • Transurethral Resection of Prostate (TURP) (95% perfomed endoscopically)
• Open Prostatectomy (When too large for endoscopic resection) (Suprapubic/Retropubic)
URINARY STONES
Definition: Aggregation of dietary minerals from the urine that forms in the kidney. 95% form in Upper Urinary Tract, 5% in Lower Urinary Tract. General Considerations: • Third most common disease • Etiology still unknown • Recurrence rate at 50% within 5 years • • • • • • • • • Factors for formation: Urine stagnation UTI Food/Drugs Abnormal Metabolism/Endocrine Dysfunction Sites of formation: Renal Ureteral Vesical Prostatic & Seminal vesicle Urethral & Prepuce Renal: Symptoms: • Pain • Hematuria • Nausea/Vomitting Diagnosis: • X-Ray • Ultrasonography • Spiral CT Complications: • Infection • Hydronephrosis • Renal tissue destruction
Treatment: Conservative: • Drugs • Water • • • • Invasive: Extracorprela Shockwave Lithtripsy (ESWL) (Using shock waves) Percuaneous Nephrolithotomy (PCNL) Trnasurethral Lithotripsy (TUL) Laparoscopy Ureteral Stones: Originates from kidney and may result in complicating infection. • • • • Symptoms: Pain Nausea/Vomiting Hematuria Infection Diagnosis: Laboratory (Same as Renal) Imaging: • CT • B Ultrasonography • KUB Complications: • Renal Damage • Anuria • Infection Treatment: • Passes spontaneously if < 0.5cm in diameter • Large stones require ureteral stent • ESWL & PCNL (When stones in upper two-third of ureter) Vesical Stone: Stones containing calcium, present in lower urinary tract. More frequent in males than females (90%) Symptoms:
• • • • •
Bladder neck obstruction Hematuria Vesical distention Urethral stricture Urethral pain & urine interruption Diagnosis:
Laboratory: • Hematuria Imaging: • X-Ray • US/CT/Endoscope Treatment: • Small stones pass spontaneously • Large stones require TUL or Vesicolithotomy
GENITOURINARY TUMOR
Kidney Cancer: Any cancer arising in kidney or renal pelvis, but most are RCC, which arise from proximal convoluted tubules. General Facts: • Renal Cell Carcinoma (RCC) accounts for 3% of malignancies • MOST LETHAL urologic cancer • More in male than female (3:1) Etiology: • Lifestyle factors (Smoking/Obesity) • Preexisting renal conditions (Polycystic renal disease/Chronic renal failure) • • • • Symptoms: Asymptomatic & nonpalpable Detected accidentally using non-invasive imaging Weight loss/fever/anemia/night sweat (COMMON SYMPTOMS) Paraneoplastic syndromes (Only found in 30% of symptomatic patients) Diagnosis: Laboratory findings: • Anemia
• Hematuria Imaging: • X-Ray • CT • Ultrasonography • • • • Staging: Stage I: Tumor < 7cm, remains in kidney, 95% of 5-year survival Stage II: Tumor > 7cm, remains in kidney, 88% of 5-year survival Stage III: Tumor in major veins, 1 regional lymph node involved, 59% 5-year survival Stage IV: Tumor beyond Gerota’s fascia, >1 lymph node involved, 20% 5-year survival
Treatment: • Radical Nephrectomy (For stages I, II, IIIa) • Partial Nephrectomy (Solitary tumor < 4cm) Bladder Cancer: General Considerations: • Most common GUT cancer in China • More than 90% are Transitional Cell Carcinomas • Superficial & Invasive • • • • • • Stages: Tis (Pre-invasive carcinoma/in situ carcinoma) Ta (Non-invasive papillary carcinoma) T1 (Tumor does not extend beyond lamina propria) T2 (Tumor invades muscle) T3 (Tumor invades perivesical tissue) T4 (Tumor invading neighboring structures) (T4a invading prostate/vagina) (T4b tumor fixed to pelvic wall)
Symptoms: • 85% present painless hematuria • 20% present irritative bladder symptoms (Dysuria/urgency/frequency) Diagnosis: Laboratory: • Testing for hematuria
• Cystoscopy (GOLDEN STANDARD) Imaging: • Intravenous Urography (IVU) • US • CT • • • • • Treatment: Principle: Based on tumor stage, patient age and general health TURBT + Instillation (Non-muscle invasive tumor) Cyestectomy (Muscle invasive tumor) (Partial or radical) Radiotherapy & Chemotherapy Intravesical Chemotherapy (Used to prevent tumor recurrence)
LAPAROSCOPIC ADRENAL SURGERY
Contraindications: • Large carcinoma with local invasion • Tumors > 12cm • Uncorrected coagulopathy • • • • • • • • • • • • • • • Transperitoneal Vs. Retroperitoneal: 25 Vs. 32 No difference Longer vs. shorter operative time Higher vs lower analgesic requirement Higher vs lower complication rate Right Adrenalectomy: Retraction of liver Peritoneal Incision Exposure of IVC Adrenal vein ligation Adrenal gland mobilization Specimen extraction Left Adrenalectomy: Trocar Insertion Mobilization of splenic flexure, spleen & tail Adrenal vein ligation Adrenal mobilization
• Colonic mobilization Advantages of retroperitoneal approach: • Avoiding potential peritoneal adhesions from previous injuries • Avoid potential visceral injury • Avoid bowel complications Bilateral & Partial Adrenalectomy Indications: • Cushing’s Syndrome • Bilateral pheochromocytomas • Bilateral aldosterone-producing tumors Conclusions: • LA is ideal for all benign tumors < 12cm • For primary malignant neoplasms & adrenal metastases • Transperitoneal approach recommended for most patients
Hernia: Abnormal protrusion of a viscus or part of a viscus through a defect either in the containing wall or within the cavity of the viscus. Involves anterior & posterior muscle layers of the abdomen, diaphragm, and walls of the pelvis. Can be either external or internal. External Hernia: Common, present as abnormal lump. (Inguinal most common in males, femoral more common in females) Richter’s Hernia: Part of the circumference of bowel trapped within hernial sac (Does not result in intestinal obstruction due to non-occlusion of lumen of bowel) Littre’s Hernia: A small bulge in the small intestine present at birth (Meckel’s diverticulum) lies within hernia sac, most common in femoral or inguinal hernia. Maydl’s Hernia: Hernial sac contains two loops of intestine that may become obstructed or strangulated. Not recognized unless hernia contents are inspected. Predisposing Factors: • Congenital (i.e. present at birth) • Acquired • Increased Intra-abdominal pressure (Coughing/vomiting/ascites) Complications: Irreducibility (least serious): Adhesions between sac and its contents Fibrosis leading to narrowing of neck of the sac Sudden increase in IAP that causes permanent displacement of the sac • • • • Obstruction: neck is sufficiently narrow to occlude the lumen of the intestine Nearly always irreducible and may become strangulated Urgent Presents with intestinal obstruction (abdominal colic, vomiting, constipation, abdominal distension) Strangulation (most serious): Compression at the hernial orifice cuts off blood supply Lymphatic and venous obstructed, leading to oedema and venous congestion Serious complication if intestine is involved Erythema of the overlying skin is a late sign
• • • •
• Immediate operation needed • • • • Reducible Hernia: Easy come, easy go Irreducible Hernia: hard to be reduced Incarcerated Hernia: Retented and confined hernia Strangulated Hernia: Causes enteric necrosis Inguinal Hernia: Most common hernia, frequent in men. Etiology: • Inguinal canal passes through the abdominal wall between the deep (internal) and superficial (external) inguinal rings • The canal is a site of weakness and therefore potential herniation Indirect Inguinal Hernia: • The neck of the sac is situated lateral to the inferior epigastric artery • Sac accompanies the spermatic cord along the inguinal canal towards the scrotum • Sac lies in front of the cord, enclosed by the coverings of the cord Causes: • failure of the processus vaginalis to form the ligamentum vaginale • loss of integrity of the inguinal canal Direct Inguinal Hernia: Rare in females, doesn’t occur in children, more common on right side after appendicectomy. Protrudes directly through posterior wall of inguinal canal, medial to the inferior epigastric artery. • • • • • • • • • • Causes: Main reason is weakness of the inguinal canal Herniation occurs at Hesselbach’s triangle Neck of a DIH is usually larger than the body and so strangulation is rare Rarely reaches a large size or approaches the scrotum Features: Inguinal discomfort Pain Severe pain suggests obstruction or strangulation. Lump usually obvious, often precipitated by increasing IAP, reduce completely with rest and lying down. The patient initially is examined standing to demonstrate the lump and possible cough impulse
• Then lying down to allow the hernia to be reduced • • • • • • • • • • Difference between IIH & DIH: IIH protrudes along the line of the inguinal canal towards the scrotum or labia DIH appears as a diffuse bulge at the medial end of the inguinal canal IIH is prevented from appearing by applying pressure over the deep inguinal ring (which lies just above the midpoint of the inguinal ligament) DIH protrudes through the posterior wall of the inguinal canal medial to the deep ring. IIH is controlled by pressure in the deep ring DIH appears medial to the examiner’s two fingers Accurate distinction may be impossible because of variation of the deep inguinal ring IIH are more likely to develop complications If the pulse lies laterally, it is indirect inguinal hernia. If the pulse lies medially, it is considered as direct inguinal hernia.
Treatment: • Inguinal hernias are best treated surgically • May under general, regional or local infiltration anaesthesia • • • • • Principles of Operation: Any correctable aggravating factors be identified and treated In infants and young adults, repair usually be limited to high ligation Eliminate the hernia sac, reconstruct the inguinal floor Bilateral repair usually discouraged; Laparoscopic repair can be done with low risk
Traditional Repair (Herniorrhaphy): • Repair posterior wall of the inguinal canal • Repair the external oblique aponeurosis • Strong non-absorbable sutures are used IMPORTANT: Bassini, Halsted, & McVay have higher chances of recurrence & is more painful, while Shouldice has lower chances of recurrence but isn’t popular. TensionFree Repair is MOST POPULAR NOW. Bassini Repair: • Conjoint tendon is sutured onto the inguinal ligament • Spermatic cord remains under the external oblique aponeurosis Halsted Repair: • Resemble Bassini repair
• Except place the external oblique aponeurosis beneath the cord McVay Repair: • Resemble Bassini repair • Except suture the conjoined tendon onto the Cooper’s ligament Shouldice Repair (GOLD STANDARD FOR HERNIORRHAPHY): • Divide the transversalis fascia • deep inguinal ring is closed around the cord • conjoined tendon and internal oblique muscle are approximated in layers to the inguinal ligament Advantages & Disadvantages: • cheap, easy to perform • recurrence rate, pain, discomfort, ect. Hernioplasty Process: • Insertion of a prosthetic mesh to cover and support posterior wall of the inguinal canal • The mesh is cut to size and is then sutured to the posterior wall behind the cord • Alternatively, the mesh can be placed deep in the defect of the posterior wall Most widely used Techniques include: • Plug--insert the plug into the internal ring, with or without sheet of mesh • Lichtenstein--use mesh to cover the entire inguinal floor • Both • • • • • • • • Laparoscopic Hernia Repair: performed under general anaesthesia, using either a transperitoneal or extraperitoneal approach not appropriate for large or irreducuble hernias Advantages of laparoscopic hernia repair include reduced post-operative pain and earlier return to work Disadvantages include increased risk of femoral nerve and spermatic cord damage, risk of developing intraperitoneal adhesions with the transperitoneal procedure, and greater cost and duration of the operation Includes Total ExtraPeritoneal approach (TEP)/ TransAbdominal PrePeritoneal approach (TAPP)/ IntraPeritoneal Onlay Mesh (IPOM) TEP is preferable to TAPP because of its lower complication and recurrence rates, the “best repair.” TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy.
• • • • •
Benefits of Biological Mesh: Safe Strong Least of infection and rejection Resists adhesions Fewer complications than synthetics
DIAGNOSIS OF URINARY DISEASES Classification of Pain:
• • • • Renal Pain: Located in the ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib. Caused by acute distention of the renal capsule, generally from inflammation or obstruction. May be associated with gastrointestinal symptoms; Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12.
Ureteral Pain: • Usually acute and secondary to obstruction. • Hyperperistalsis and spasm Vesical Pain: • Inflammatory conditions of the bladder usually produce suprapubic discomfort • Acute urinary retention • Overdistention and inflammation Prostatic Pain: • Usually secondary to inflammation with secondary edema and distention of the prostatic capsule; • Poor localization Penile Pain: • Usually secondary to inflammation in the bladder or urethra, pain at urethral meatus. Testicular Pain:
• Primary pain arises from within the scrotum, secondary to acute epididymitis • Chronic scrotal pain is usually related to noninflammatory conditions • The pain is generally characterized as a dull, heavy sensation that does not radiate. HEMATURIA: ＞3 red cell per High-power field IMPORTANT: Urinary infection is the most common cause of hematuria. • • • • Classification: Hematuria gross or microscopic At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)? Pain association If the patient is passing clots, do the clots have a specific shape?
Differences: • Initial hematuria usually arises from the urethra; • Total hematuria is most common and indicates that the bleeding is most likely coming from the bladder or upper urinary tracts. • Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra. Association with Pain: • Pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots. • Acute urinary infection (most common cause of hematuria) Shape of Clots: • The presence of wormlike clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract; • Hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise and demands immediate urologic examination. • • • • • Differential Diagnosis Evaluation of Hematuria: Glomerular Hematuria. IgA Nephropathy (Berger's Disease), the most common cause of glomerular hematuria, accounting for about 30% of cases . Nonglomerular Hematuria The urinalysis in nonglomerular hematuria is distinguished from that of glomerular hematuria by the presence of circular erythrocytes and the absence of erythrocyte casts.
ABNORMALITY OF VOIDING VOLUME • • • • • • • • Classification: Polyuria: Greater than 2000ml per day with normal drinking (diabetes, diabetes insipidus and polyuria stage of renal failure, etc.); Oliguria: Less than 400ml per day with normal drinking; Anuria: Less than 100ml per day (prerenal, renal and postrenal anuria) Prerenal anuria: Inadequate of renal irrigation; Renal anuria: Dysfuntion of urinary production; Postrenal anuria: Obstruction of urinary tract. SYMPTOMS: Irritative: • Frequency; • Urgency; • Dysuriea • • • • • Obstructive: Decreased force of urination; Urinary hesitancy (delayed start of urination) Intermittency (occasionally stop during urination) Postvoid dribbling; Straining INCONTINENCE • • • • • • • • • • Classification: Continuous Incontinence; Stress Incontinence; Urgency Incontinence; Overflow Urinary Incontinence; Enuresis; SEXUAL DYSFUNCTION: Loss of Libido; Impotence; Failure to Ejaculate; Absence of Orgasm; Premature Ejaculation;
• Hematospermia; Diagnosis: Physical Examination Urinalysis (Midstream urine sample preferred) Abdominal Plain Radiography Intravenous Urography (Requires normal renal function, For Renal Parenchyma and evaluating Hematuria/Urolithiasis) CT Ultrasound MRI
• • • • • • •
Invasive Examination: • Cystoscope/Ureteroscope/Nephronscope • Retrograde Urography/ Urethrography (Performed by cystoscope/urethral meatus GENITOURINARY TRAUMA • • • • • • • • • • • • • • • General Considerations: 10% of E.R. trauma visits Often associated with multi-system trauma Subtle presentations, easily overlooked Diseased GU organs susceptible to injury Evaluation (Primary Survey): Airway with Cervical spine protection Breathing high-flow oxygen Circulation control of external bleeding, 2 large-bore IVsDisability assessment of neurologic status Disability assessment of neurologic status Exposure / Environment undress / temperature control Renal Trauma: General Considerations: • Most commonly injured GU organ • Often in association with multi-system organ injury
• －must be suspected in individuals with chest,abodominal or back injury • Blunt >80% • Penetrating <20% Types of Trauma: • • • • • • • • • • • • • • • • • • • • Blunt: Most common form of renal trauma Types of injury Motor vehicle accidents Falls from heights Assaults Mechanisms of injury High velocity impact (contusion / hematoma / laceration) Deceleration injury (RA thrombosis / RV disruption / avulsion of renal pedicle) Penetrating: Uncommon form of renal trauma Types of injury Gunshot wounds Stab wounds Mechanisms of injury Direct shearing force through renal tissue Presentation: Hematuria (gross or microscopic) Microscopic = 5 RBCs/HPF May be absent Shock (hypotension, tachycardia, oliguria) Flank bruising/ palpable mass Flank pain/tenderness
Diagnosis: • CT • • • • Classification (Using AAST): grade I : contusion or non enlarging subcapsular haematoma, but no laceration ; grade II : superfical laceration < 1cm depth and does not involve the collecting system ; non expanding perirenal haematoma grade III : laceration > 1cm, without extension into the renal pelvis or collecting system and with no evidence of urine extravasation grade IV : laceration extends to renal pelvis or urinary extravasation.
• grade V : shattered kidney ; devascularisation of kidney due to hilar injury. Non-operative management: Hemodynamic stable patient with an injury well staged by CT can usually be managed with nonoperative 98% of renal injuries can be managed nonoperatively bed rest increased fluid intake antibiotids close observation Grade IV &V injuries more often require surgical exploration Surgical Indications: Absolute: • Persistent renal bleeding with hemodynamic instability • Expanding perirenal hematoma • Pulsatile perirenal hematoma • • • • • Relative: Penetrating injuries Extensive urine extravasation Grade 5 injury Non-viable tissue (>20%) Arterial injury (main or segmental)
• • • • • • •
Methods: • partial nephrectomy • nephrectomy (normal contralateral kidney) • • • • • • • • • IMPORTANT: TOTAL NEPHRECTOMY ONLY IF: the vasculature is completely avulsed . the kidney is ischemic . the kidney is the site of life threatening uncontrolable hemorrhage. Principles of Renal Reconstruction: Complete renal exposure Debridement of non-viable tissue Hemostasis Suture ligature (Gelfoam, Surgicel/Argon beam coagulation) Water-tight closure of collecting system
• Approximation/coverage of parenchymal defect Complications: Early: • Urine extravastion (most common) • Hemorrhage, shock • Urinoma formation • • • • Late: Infection Abscesses Loss of renal function Hypertension Bladder Trauma: • • • • • General Conisderations: Relatively uncommon Often in association with multi-system organ injury Significant mortality rate (10-20%) Have high index of suspicion of urethral disruption injury Bladder more susceptible to injury when full Types of Trauma: • • • • • • Blunt: Most common type of bladder injury Usually motor vehicle accidents 2/3 contusions, 1/3 ruptures Associated with pelvic # 10-25% of pelvic #’s have associated bladder injury 85-90% of bladder injuries have associated pelvic #
PENETRATING • Less common • Often associated with major organ injuries IATROGENIC • Open or laparoscopic pelvic surgery • Gynecologic, vascular, urologic or general surgery • SPONTANEOUS RUPTURE
• Underlying pathology • Cancer, obstruction, XRT, TB, sensory neurologic deficit • • • • • • • • Presentation: Gross hematuria (the classic finding) 95% blunt injuries have gross hematuria Inability to void Abdominal pain Abdominal bruising Pelvic mass Peritoneal signs Shock Classification: Extraperitoneal injury : Most common treatment by catheter drainage Surgery when : Bone fragment into bladder Open pelvic Fracture Rectal perforation Poor catheter drainage
• • • • • •
Intraperitoneal injury : • Rapid raising intraperitoneal pressure cause of the bladder burst, dome • Surgery treatment Complications: Intraperitoneal • Urinary frequency • Shock • Peritonitis Extraperitoneal • Shock • Pelvic abscess Ureteral Trauma: Etiology: • External trauma very rare • <4% of penetrating trauma • <1% of blunt trauma
• Look for concomitant visceral injuries (SB, LB, K, B) • Usually surgical trauma (Gynecologic, vascular, urologic or general surgery/Open/Laparoscopic/Ureteroscopy) Presentation: • At time of external trauma • If unrecognized intra-op, then:Low grade fever, ileus, Flank pain, Fluid drainage from incision, drain sites • Hematuria may be absent • • • • • • • • • • • • • • • • • • • Diagnostic Tests: Methylene blue IV or renal pelvic injection For suspected intra-op ureteral injury Allows localization of injury IVP CT scan Ureteropyelogram Retrograde Antegrade Surgical Indications: Ureteric injury during operation The most common cause; surgical trauma during hysterectomy or other pelvic surgery Preoperative catheterization of the ureters makes them easier to identify during surgery Injuries discovered at the time of surgery should be repaired immediately Injury not recognized at the time of operation Unilateral injury :3 possibilities No symptoms :ligate ureter lead to silent atrophy kidney Loin pain and fever :pyonephrosis Urinary fistula :through the abdominal or vaginal wound, tempolary nephrostomies Bilateral injury (Anuria) Complications: Early: • Hydronephrosis • Urinoma
• Infection Late: • Stricture • Loss of renal function • Stone formation Testis Trauma: • • • • • • General Considerations: Usually due to blunt trauma Sports, fights 1-2% of gunshot wounds Pain, scrotal hematoma, bruising Physical exam often difficult due to pain and degree of swelling U/S most useful investigation (To determine if ruptured)(May miss tunical fracture)
Management: • Most cases are low grade injuries (contusions or hematomas) and are therefore managed non-operatively (Ice, analgesics, bedrest/activity restrictions • Indications to operate:Rupture of tunica albugineaExpanding or large hematocele Intratesticular hematoma • Surgery: Repair vs. orchidectomy URINARY TRACT INFECTION IMPORTANT DEFINITIONS: Upper urinary tract infection: infection occurs in kidney, pelvis and ureter • Lower urinary tract infection: infection occurs in bladder and urethra • Cystitis: infection occurs mainly in bladder, and usually with urethritis • Urethritis: infection occurs mainly in urethra • • • • Classification: Upper urinary tract infection or lower urinary tract infenction Pyelonephritis vs cystitis vs urethritis first infection vs recurrent infection Complicated vs uncomplicated
Diagnosis: • Location of infection: upper or lower • Pathogen: urine culture
• Any anatomic abnormalities in urinary tract Pyelonpehritis: • • • • • • Symptoms: Fever Flank pain Tenderness on flank Dysuria Urinary urgency Urinary frequency Cystitis: • • • • • • • Symptoms: Dysuria Urinary urgency Urinary frequency with Hematuria suprapubic pain foul-smelling urine No fever Complicated vs Uncomplicated: Patients with uncomplicated cystitis • occasionally occurred annually • No history of abnormalities in urinary tract • 80% UTI resulted in with E Coli • • • • • • • • Management: Hydration-drinking more water No need to do urine cultrue Antibiotics 1. TMP-SMX(trimethoprim-sulfamethoxazole) for 3 days 2. fluoroquinolone (Ciprofloxacin, Levofloxacin) for 3 days If urine analysis is still not negative after that 1. urine culture 2. antibiotics based on urine culture
Patients with complicated cystitis • recurrence in recent three months • history of abnormalities in urinary tract
• • • • • • • • • •
history with multiple antibiotics previously pathogen diagnosis should be based on urine culture Management: Urine culture for recurrent UTI Ultrasound screening for any abnormalities of urinary tract CT scan or IVU for any abnormal finding from ultrasound screening Uroflowmetry with residual urine for patient with difficult voiding Control Diabetes Mellitus Antibiotics in initial stage: in first week 1. TMP-SMX(trimethoprim-sulfamethoxazole) 2. fluoroquinolone (Ciprofloxacin, Levofloxacin) Antibiotics should be based on urine culture The effective antibiotics should be maintained for over two week Prostatitis:
• • • • • • • •
Classification: Acute bacterial prostatitis-category 1 Acute urinary symptoms with bacteremia • Chronic bacterial prostatitis-category 2 Chronic urinary symptoms with bacteria in prostate • Nonbacterial prostatitis-category 3 Chronic urinary symptoms without bacteria in prostate • asymptomatic prostatitis-category 4 inflammation in prostrate without symptoms and bacteria in prostate Category 1:
• • • •
Symptoms: UTI symptoms: dysuria, urgency, frequency, nocturia, perineal, low back • Urinary hesitancy, fever, chills, malaise • Enlarged, tender prostate on DRE • Minimize rectal exams for fear of urosepsis Treatment:
pain
• • • • •
Category 1: Bed resting, antipyretics, hydration urine culture for antibiotic sensitivities Suprapubic drainage if patient were in urinary retention Treat with broad spectrum antibiotics parenteraly until sensitivities are back Continuing oral proper antibiotics for 4 weeks after controlling acute symptoms to eradicate bacteria in prostate
Category 2: Symptoms: • Episodes of dysuria, frequency, pelvic, perineal pain, usually without fever • Prostate secretion test culture should be done for further treatment • • • • • • • • Treatment: Antibiotics option E coli present in 80% of cases, Klebsiella, Pseudomonas aeruginosa, Proteus less common TMP-SMX and fluoroquinolones orally are the first line for 4~6 weeks Option could be based on culture sensitivities when it is available other adjuvant therapy α-blocker: could relieve urinary symptoms analgesics: could relieve chronic pain cernilton: pollen agents Orchitis: Classification: • • • • • • • • • • • Acute bacterial orchitis Secondary to UTI Secondary to STD Nonbacterial infectious orchitis Viral Fungal Parasitic Rickettsial Noninfectious orchitis Idiopathic Traumatic Autoimmune Chronic orchitis Chronic orchialgia Clinical Manifestation: Symptoms: • Unilateral testis pain and swollen • Fever ( acute cases) • abdominal discomfort, nausea, and vomiting
• The skin of the involved hemiscrotum is erythematous and edematous • Most cause of bacteria is E.Coli and Pseudomonas Treatment: Systemic support bed rest scrotal support Hydration Antipyretics anti-inflammatory agents analgesics Antibiotic therapy Same principle as acute or chronic bacterial prostatitis Paranteral antibiotics for acute cases Oral antibiotics for 4~6 weeks Fluoroquinolone should be the first line of option GENITOURINARY TUBERCULOSIS • • • • • • • • • • • • • • • Definition: Tuberculosis involving kidney, ureter, bladder and male genitals It should be taken as a part of systemic Tuberculosis Cause is Tubercle bacillus Clinical Manifestation: Frequency, urgency and dysuria Hematuria Pyuria Lumbago Systemic Symptoms Diagnosis: Urine Rt Acid Fast Staining Urine Culture US KUB+IVP CT & MRI
• • • • • • • • •
• Cystoscopy • • • • • Treatment: Systemic Therapy Chemotherapy Surgical Treatment (Nephrectomy/Reconstructive Surgery) Postoperative Chemotherapy Bladder Contracture (Only considered after cure of TB) Male Genitals TB: Clinical Manifestation: • Non-tenderness nodules in prostate • Non-tender swelling of vas deferens • Fistula formation of scrotum Symptoms & Treatment: SAME FOR TYPICAL GU TB URINARY TRACT OBSTRUCTION • • • • • Classification: Congenital or Acquired Mechanical or Dynamical Upper urinary tract or Lower urinary tract Disorders of the tract or other systems Upper Urinary (Kidney/Ureter/Multifactoral) or Lower Urinary (Prostate/Urethra) Tract Congenital UPJ Obstruction: Causes: • Congenital (Aperistaltic segment of ureter) • Acquired (Compression from bands) Results of UTO: • Lowered GFR • Lowered Renal Blood Flow Complications: • Renal Parenchymal Atrophy (Renal Failure) • Urosepsis (Bacteria in circulatory system)
Hydronephrosis: Blockage in urine drainage from pelvis, leading to elevated pelvic pressure and dilated calyces, resulting in renal parenchyma atrophy (Renal failure). Severity depends on: • Duration • Degree (Complete or Incomplete) • Site • • • • Symptoms: Congenital (Asymptomatic to abdominal mass) Acquired (Symptoms of primary disease) Complete Obstruction (Renal Colic) Intermittent (Persistent and complete obstruction)
Diagnosis: • Confirmation • Severity & Renal Function Clinical Findings: Laboratory: • Infection (Urinalysis/Leukocytosis) • Renal Function (Azotemia/Electrolyte Imbalance) • • • • • • Imaging: Sonography (Thin renal parenchyma) KUB Excretory Urography (Reveals entire cause unless severely impaired renal function) Retrograde Uropathy (Percutaneous Urography in case of failure) CT & MRI (Differentiate from solid tumors) Isotope Scan
Treatment: • Treating primary disease • Relief of obstruction (JJ-Drainage/Nephrostomy) • Nephrectomy (ONLY in Irreversible kidney damage) BENIGN PROSTATIC HYPERPLASIA Definition: Hyperplasia of prostatic epithelial cells that leads to formation of large nodules in periurethral region, why may eventually cause complete obstruction of the urethra.
General factors: • Mostly occurs in peripheral zone • Most common benign tumor in men • • • • • • • • Symptoms: Men > 50yrs. Prostate size has poor correlation with symptoms (Middle lobe causes severe symptoms) Severity based on obstruction, progressive speed, and associated infection Urination frequency, urgency, nocturia & dysuria Symptoms of Complications: UTI Odynuria Bladder stone Hematuria Renal failure (Hydronephrosis)
IPSS: International-Prostate Symptom Score, used to determine severity. • Mild: 0-7 • Moderate: 8-19 • Severe: 20-35 IMPORTANT: BPH determined by Digital Rectal Examination (DRE). • Tone of anal sphincter • Prostate size & consistency • Nodules • • • • • • Diagnosis: DRE Uroflowmetry Urodynamic Study Ultrasonography Prostate Specific Antigen (Marker for Prostate Cancer) Cystoscopes (When Transitional Cell Carcinoma suspected)
Treatment: • Watching waiting • Medical therapy (Alpha-blockers/Finasteride) • Phytotherapy (Plant extracts) Surgical Treatment: • Transurethral Resection of Prostate (TURP) (95% perfomed endoscopically)
• Open Prostatectomy (When too large for endoscopic resection) (Suprapubic/Retropubic)
URINARY STONES
Definition: Aggregation of dietary minerals from the urine that forms in the kidney. 95% form in Upper Urinary Tract, 5% in Lower Urinary Tract. General Considerations: • Third most common disease • Etiology still unknown • Recurrence rate at 50% within 5 years • • • • • • • • • Factors for formation: Urine stagnation UTI Food/Drugs Abnormal Metabolism/Endocrine Dysfunction Sites of formation: Renal Ureteral Vesical Prostatic & Seminal vesicle Urethral & Prepuce Renal: Symptoms: • Pain • Hematuria • Nausea/Vomitting Diagnosis: • X-Ray • Ultrasonography • Spiral CT Complications: • Infection • Hydronephrosis • Renal tissue destruction
Treatment: Conservative: • Drugs • Water • • • • Invasive: Extracorprela Shockwave Lithtripsy (ESWL) (Using shock waves) Percuaneous Nephrolithotomy (PCNL) Trnasurethral Lithotripsy (TUL) Laparoscopy Ureteral Stones: Originates from kidney and may result in complicating infection. • • • • Symptoms: Pain Nausea/Vomiting Hematuria Infection Diagnosis: Laboratory (Same as Renal) Imaging: • CT • B Ultrasonography • KUB Complications: • Renal Damage • Anuria • Infection Treatment: • Passes spontaneously if < 0.5cm in diameter • Large stones require ureteral stent • ESWL & PCNL (When stones in upper two-third of ureter) Vesical Stone: Stones containing calcium, present in lower urinary tract. More frequent in males than females (90%) Symptoms:
• • • • •
Bladder neck obstruction Hematuria Vesical distention Urethral stricture Urethral pain & urine interruption Diagnosis:
Laboratory: • Hematuria Imaging: • X-Ray • US/CT/Endoscope Treatment: • Small stones pass spontaneously • Large stones require TUL or Vesicolithotomy
GENITOURINARY TUMOR
Kidney Cancer: Any cancer arising in kidney or renal pelvis, but most are RCC, which arise from proximal convoluted tubules. General Facts: • Renal Cell Carcinoma (RCC) accounts for 3% of malignancies • MOST LETHAL urologic cancer • More in male than female (3:1) Etiology: • Lifestyle factors (Smoking/Obesity) • Preexisting renal conditions (Polycystic renal disease/Chronic renal failure) • • • • Symptoms: Asymptomatic & nonpalpable Detected accidentally using non-invasive imaging Weight loss/fever/anemia/night sweat (COMMON SYMPTOMS) Paraneoplastic syndromes (Only found in 30% of symptomatic patients) Diagnosis: Laboratory findings: • Anemia
• Hematuria Imaging: • X-Ray • CT • Ultrasonography • • • • Staging: Stage I: Tumor < 7cm, remains in kidney, 95% of 5-year survival Stage II: Tumor > 7cm, remains in kidney, 88% of 5-year survival Stage III: Tumor in major veins, 1 regional lymph node involved, 59% 5-year survival Stage IV: Tumor beyond Gerota’s fascia, >1 lymph node involved, 20% 5-year survival
Treatment: • Radical Nephrectomy (For stages I, II, IIIa) • Partial Nephrectomy (Solitary tumor < 4cm) Bladder Cancer: General Considerations: • Most common GUT cancer in China • More than 90% are Transitional Cell Carcinomas • Superficial & Invasive • • • • • • Stages: Tis (Pre-invasive carcinoma/in situ carcinoma) Ta (Non-invasive papillary carcinoma) T1 (Tumor does not extend beyond lamina propria) T2 (Tumor invades muscle) T3 (Tumor invades perivesical tissue) T4 (Tumor invading neighboring structures) (T4a invading prostate/vagina) (T4b tumor fixed to pelvic wall)
Symptoms: • 85% present painless hematuria • 20% present irritative bladder symptoms (Dysuria/urgency/frequency) Diagnosis: Laboratory: • Testing for hematuria
• Cystoscopy (GOLDEN STANDARD) Imaging: • Intravenous Urography (IVU) • US • CT • • • • • Treatment: Principle: Based on tumor stage, patient age and general health TURBT + Instillation (Non-muscle invasive tumor) Cyestectomy (Muscle invasive tumor) (Partial or radical) Radiotherapy & Chemotherapy Intravesical Chemotherapy (Used to prevent tumor recurrence)
LAPAROSCOPIC ADRENAL SURGERY
Contraindications: • Large carcinoma with local invasion • Tumors > 12cm • Uncorrected coagulopathy • • • • • • • • • • • • • • • Transperitoneal Vs. Retroperitoneal: 25 Vs. 32 No difference Longer vs. shorter operative time Higher vs lower analgesic requirement Higher vs lower complication rate Right Adrenalectomy: Retraction of liver Peritoneal Incision Exposure of IVC Adrenal vein ligation Adrenal gland mobilization Specimen extraction Left Adrenalectomy: Trocar Insertion Mobilization of splenic flexure, spleen & tail Adrenal vein ligation Adrenal mobilization
• Colonic mobilization Advantages of retroperitoneal approach: • Avoiding potential peritoneal adhesions from previous injuries • Avoid potential visceral injury • Avoid bowel complications Bilateral & Partial Adrenalectomy Indications: • Cushing’s Syndrome • Bilateral pheochromocytomas • Bilateral aldosterone-producing tumors Conclusions: • LA is ideal for all benign tumors < 12cm • For primary malignant neoplasms & adrenal metastases • Transperitoneal approach recommended for most patients
