د.ممد فوزي pdf - clinical urology

Clinical urology

stage

2016 / 2017

Dr. Mohammed fawzi

Assi.Prof

Ninavah college of medicine

Anatomy :

  the kidney extend from L1-L3
  kidney and ureter is retroperitoneal
  uretropelvic junction{UPJ} :between the ureter and the kidney [ if

obstructed will cause UPJ obstruction and hydronephrosis]

 uretrovasical junction : between the ureter and bladder{ if dilated will

cause uretrovasical reflux}

 the the urethra is 2 part :

1. posterior urethra : prostatic – membranous
2. anterior urethra : bulbar – perenial

 the epithelial lining the urinary system is transitional cell
 the kidney is consist of cortex and medulla ( the thickness of cortex

reflect the function …much thickness more function )

 the pelvic and ureter and bladder is low pressure system to alow the

urine to descent into the bladder .the urine is descent by gravity and
peristalsis of the ureter( if the pressure increase inside the bladder or
ureter this will prevent the urine from descend and cause hydronephrosis
and gradually renal failure )

 the capacity of the bladder is 350-500 ml

investigation in urology

general urine examination

 we see :the color -pus cell - cast - RBC



the food and drug (rifampicin-flagel ) may change the
color of the urine

2. us :

advanteges : a. simple b.not coasty

disadvanteges : cant see the function of the kidney .cant see the
most of the ureter …

KUB

{ kidney. Ureter. Bladder}

It is a plane X-ray taken from the level of L1 to bladder
In the KUB we can see :



bone



Soft tissue shadow like …. liver. Kidney.psoas muscle



Radio opaque shadow …..stone ( normal KUB doesn't mean
absent of stone . it may be radiolucent)



Gas appear as a black

4. IVU:

is to confirm the diagnosis



IVU is for functional and anatomical



We must do an KUB before the IVU



Contraindication is sensitivity and RF

If we want to exam the renal function we
must do urea and createnin .but if we want
to exan a single kidney function we must do
a IVU and renal isotop scan

5. CT scan :

it will show anatomy .it is the definitive diagnosis .but have a

high radiation

6. Redionucli study :

for the function of the kidney

7. MRI :

give anatomy and pic .no radiation

8. MRU:

for patient with sensitivity to IVU

9. MCUJ :(

macturating cystourethrogram

)

for diagnosis of uretro

vesical reflux

10.

RETROGRADE

urethrograph :

for the diagnosis of urethral

problem

Stone

Type of stone :

1)  Ca oxalate is the commonest
2)  Ammonium magnesium & phosphate (staghorn stone)
3)  Uric acid stone
4)  Cestein stone

 AMP stone

تتجمع

في

الوسط

القاعدي

 Uric acid stone

تتجمع

في

الوسط

الحامضي

Anuria :patient have no urine  output, the most common
cause is ureteric obstruction by stone in a patient have only
one kidney ,rarely obstruction in both ureter ,its emergency
.we should put a foley catheter  in the bladder to exclude
acute retention of urine where the bladder is full while it is
empty in case of unuria ,also we should  send for renal
function test (urea and creatinine) to see the state of the
patient because unurea usually lead to renal failure if not
treated rapidly
Treatment
Insertion of nephrostomy tube (open or percutaneous ),or
we insert double j stent we should put an nephrostomy(
urinary diversion)  and check the renal function test to know
the severity of the case

Acute retention of urine

no urine with full bladder usually due to obstruction in the
bladder or urethra .it is diagnosed clinically . and it resolved
by butting a foley catheter

 Acute retention of urine ---- foley catheter
 Anuria ---- nephrostomy

Pyelonephritis

1 .pain 2. Fever 3. Rigor 4. Tenderness 5.pyuria 6.may
associated with vomiting

  It is usually occur unilateral and with D.M
  If the U.S is normal – use simple antibiotic
  If U.S show complication ( stone . hydronephrosis ):

1.hospital admition . parenteral antibiotic until fever is gone we
change to oral antibiotic for 10-14 day
2 .I.V fluid

Cystitis

1.  Frequency
2.  Dysuria
3.  Nocturia
4.  Urgency
5.  Pus +RBCs in urine
6.  Low grade fever
7.  Suprapubic pain or discomfort

Diagnosis,
Clinically and GUE
Treatment by antibiotic for 3 –5 days

Renal tumor

 Benign ( rare )

 Malignant

Presentation -

1. nowadays 50 % discovered accidentally in early stage

2. Trade ( pain - hematuria - mass )

Hematuria is painless ( any patient with painless hematuria we

must suspect renal and bladder tumor )

3. Paraneoplastic syndrome: hypercalemia - anemia - abnormal
liver function test - fever - hypertension - elevated ESR

Investigation

1. GUE 2. US 3. CT-scan ( for staging )

# For grading ( histopathology )

# CT of the brain and lung ( if there is any symptom of

metastesis )

# ESR - - Calecium - liver function test for follow up

If it still elevated after nephrectomy, we think about metastasis

Treatment of renal tumor

1. localized tumor (t1,t2,t3 ) ,do radical neprectomy

2. partial nephrectomy done for small tumor ,less than 7 cm

or when the tumor ocure in apatient with single kidney

3. metastasis use immune therapy ( interferon & IL )

( chemotherapy and radiotherapy are not effective )

 Prognosis of renal tumors : there is possibility of recurrence so follow

up should be continuous up to 2-3 years. The smaller the tumors at
time of diagnosis the more good prognosis

 If after 5 year there is no recurrence we can say it is cured

Pyonephrosis

is an infection in an obstructed hydronephrotic kidney ,its
emergency ,if not treated within days lead to destruction of the
kidney

 Hydronephrosis

fever = pyonephrosis

Dx: 1- GUE ,ULS , CT SCAN ,Tapping for confirmation

Treatment , by emergency drainage of the kidney by doubl j stent or
nephrostomy tube insertion WITH ATIBIOTIC

Simple renal cyst

Dx: 1. U/S is enough 2. CT scan for confirm diagnosis

Rx:

1.asymptomatic : reassurance

2.if it is large enough to cause pressure symptoms (hydronephrosis,renal
pain ) do murcipulization by open or laparoscopy

Bladder outlet obstruction

 Symptom ( lower urinary tract symptom )

( Frequency – dysuria – nucturia – hesitancy – terminal drippling –
intermittency – urgency )



D.DX. (

BPH – ca prostate –urethral stone – neurogenic blader –

urethral stricture )

urinary retention

( acute – chronic – acute on chronic )

 chronic : if the residual volume is 500 and more ( normal 0 ) and it

may lead to renal failure

increase frequency – decrease volume of urine that urinate - increase
residual volume – may cause reflux – bilateral hydronephrosis – renal
failure

 acute retention : sudden in ability to void with pain

 precipitation : cold weather – delay the act of micturition – stress

– diuresis - anticholinergic drugs

 Contraindicated drug to use is : anticholinergic – decongestant

with epinephrine )

 Presentation : pain – desire to void
 Rx : foley catheter : if fail supra pubic catheter , if not available

suprapubic aspiration by needle

 Acute on chronic : sudden retention of urine in patient who is

already have chronic retention

We can know that it is chronic if :

1. amount of urine collected in the bag by foley catheter is more
than 1000 and its painless

2. by US

3. by percussion ( it will be tender in acute and not tenderness in
chronic )

 To differentiate BPH from neurogenic bladder 0r CVA or

disc prolapse ( in these cases there will be an associatiated
neurological symptom )

 From Urethral stricture ( the catheter cant be inserted )

BPH

( BENIGN PROSTATIC HYPERATROPHY )



1.  GUE ( to exclude cystitis )
2.  P.S.A
3.  US ( kidney – bladder – prostate ,post voiding residual

volume

4. P.R
5. bladder examination

6. nervous system examination ( if we suspect neurogenic

bladder )
urodynamic study ( if we suspect neurogenic bladder )

 Causes of BPH

1) aging
2) androgenic effect ( testesteron )

 Method of treatment :

1) conservative ( for mild cases )

عدم شرب أي شي ليال

–

عدم التعرض للبرد

–

عدم استعمال أي شي يضعف المثانيه

2) medical ( if the symptom progress )

A) Anti androgen ( 5 alph reductase inhibitor ) . it need 6

month to work .so we give alfa- blocker until it work

S.E: loss of lipido – impotence

B) ( a-blocker ) cause relaxation of smooth muscle of the

prostate

S.E : hypotension – syncope –retrograde ejaculation

3)  surgery : indication



Sever symptom



No benefit of medical treatment



Appearance of complication ( stone – repeated
hematuria –repeated UTI – R.F – acute or chronic
retention)

1. TURP ( trans urethral resection of prostate )



Complication ( bleeding during and after
operation – )



Post TURP syndrome : due to use of water
during operation – the water wil be absorped –

cause - delusional hyponatremia and brain
oedema leading to confusion and even comma



Dx of post TURP syndrome is by measuring
serum NA level



Rx : use of hypertonic saline



To avoid TURP SYNDROM we should use
normal saline instead of water during operation
with bipolar resectoscope

After TURP we insert a 3 ways foley catheter

way for irrigation ( to avoid clot formation in

the bladder )

way for evacuation of urine

line for the balloon inflation

2. Open prostatectomy

Open trans vesical prostatectomy ( by supra vesical
incision )

3. Minimal invasive ( if the patient are not compatible

with the surgery
Trans urethral microwave therapy – trans urethral
needle ablation – balloon dilatation – stent application

 Complication of TURP and open prostatectomy

Early

– bleeding ( during and post operative ),
Clot retention which if occur treated by cystoscopy
and evacuation of clot by ellik evacuator

Late

Urethral stricture – recurrence – impotence –
retrograde ejaculation – incontinence,
Open prostatectomy have a complication of wound
like wound infection in addition to a previous
complication

AFTER SURGERY WE SEND THE SPECIMEN FOR THE
LAB FOR CITOLOGICAL EXAMINATION TO EXCLUDE
MALIGNANCY

foley's catheter

    األلوان تكون حسب الحجم
  It should not stay more than three (3) week and
  Replaced

Indication

1.  For treatment of acute or chronic retention
2.  Irrigation
3.  Calculate urine volume
4.  After operation for the urethra . bladder or open

prostatectomy ,TURP,TURBT

5. For diagnostic purpose as in

Micturiting cystourethrographe ,Retrograde urthrography

6. For intravesical chemotherapy

Complication

  Infection
  Stone formation
  Injury to the urethra and urethral stricture
  In ability to remove it

We must sure that the ballone is reached the bladder before we
inflate it > and we deflate it before remove it

Vesico uretral reflux

 Presentation: Repeated UTI IN INFANT AND CHILDREN
 Diagnosis : mucturating cystourethrographe ( MCUG )

Grade 1 …. Urine reach the ureter
Grade 2 ….. urine reach the kidney but no dilatation

Grade 3 ….. urine reach the kidney with mild dilatation
Grade 4….. urine reach the kidney with sever dilatation
Grade 5…. The urine reach the kidney with sever dilatation and tortuosity
of the ureter

Treatment :

Grade ( 1- 2 ) : prophylactic antibiotic ( 1/3 of the
dose of the UTI – trimethoprim at night )

Grade ( 3- 4 -5 ) : 1. surgery ( reimplantation of the
ureter )

2 . Subtrigonal injection of
special substance ( tephlon like ) causing obstruction

Contra indication of the IVU

1.  Allergy to the dye
2.  Renal failure
3.  Diabetic patient using Glucophage ( must stop it because

2 weeks )

Congenital anomalies ( general feature to all )

1.  They are asymptomatic
2.  Accidental diagnosed
3.  If symptom will present it mainly due to  (hydronephrosis –

repeated infection – stone )
Investigation : the best is IVU for all of them
Treatment : reassurance – treatment of complication ( UTI .
stone .

Differential diagnosis for absent of the kidney in KUB

1.  Agenesis
2.  Non functioning kidney
3.  Nephrectomy
4.  Ectopic kidney

Urethral stricture

 Causes : 1 . congenital

2. inflammatory(gonorrhea)
3. traumatic ( external – iatrogenic )

 Presentation :

1. Obstructive symptom : gradual weak stream of urine
2. Acute retention of urine

 Diagnosis :

1.  Urethrographic
2.  Urethroscope
3.  U.S

 Treatment :
1. Dilatation by metallic dilator ( may recure so need repeated

dilatation)

2. Urethrotomy by endoscopic laser or knife
3. Urethroplasty ( cut of the stricture )

Congenital PUJ obstruction

Presentation

According to the severity
1. May discovered accidentally
2. A mild case may present at any age

3. It could be very sever that cause sever

hydronephrosis ( and nephrectomy done in early
life)

4. Pain after drinking a large amount of water or

using diuretics (details crisis)

5. Repeated infection
6. If it is bilateral and severe form it may cause renal

failure

  Complication :
1. Repeated UTI  and stone
2. If bilateral it will cause renal failure
3. If unilateral it will cause destruction of the kidney

 Diagnosis :

1. Renal isotope ( with diuretic or diuretic renogram )
2. IVU (dilated pelvis and usually upper ureter not

seen)

 TREATMENT

In mild case reassurance and follow up

Indication of surgery

 Repeated pain and infection
 Progressive hydronephrosis and deterioration of

renal function

 Renal stone formation

Types of surgery

 Pyeloplasty ( open and laparoscopic)

 Endoscopic pyelotomy through ureteroscope

or nehroscope

Testicular swelling



painful

(acute)

  torsion of the testes
  torsion of testicularand epidedymal appendages
  strangulated inguinal hernia
  epidydemitis(acute)
  fourneirs  gangrene of scrotal wall
  varicosity could be (dull aching pain long duration Or painless)
  trauma
  10 percent of testicular tumor

Investigation

o Send for US immediately
o Doppler US especially useful in :

1.torsion (check vascularity)

2. varicosity



painless

  tumor
  hydrocele
  epidydemal cyst
  spermatocele

Torsion of testis

نفكر بيهاًامئاد مزلا(

)

Testicular torsion

 occur in adolescent(mainly) but any age can be affected, neonatal

torsion

  if missed for 12 h lead to loss of the testes as a result of ischemia
  sudden sever attack of pain
  radiate to the lower abd. With vomiting

  awake him from sleep at mid night
  swelling start with 1_2 hr
  usually unilateral

O/E: swelling , red ,tender , higher in position (abnormal lying)

DDx:

o  epidydemitis(associated with fever)
o  sometimes UTI
o  torsion of appendages

*to differentiate between (epidydemitis and torsion ) we do perhens
sign

If we lift the testis pain increase in torsion and decrease in epidydemitis

Dx : Doppler US is diagnostic



Management:

--early stage manual detortion if possible

--Exploration when ever you suspect it if the testes still viable

Orcheopexy done, The other side should also be fixed by orcheopexy
also

If the testes is "gangrene" ..orcheoctomy and orcheopexy for the other

Hydrocele

Abnormal accumilation of fluid within tunica vaginalis around the testis

 primary : without cause , gradual , young adult

Symptoms : heaviness , mild pain

 Secondary

Causes : tumors , trauma , epidimytis , post operative

 Congenital hydrocele (communicating)

Continue with peritoneum by patent processus vaginalis

Appear after birth

•

: of congenital hydrocele

Wait until 1yr if remain …..do surgery by ligation of the patent procassus
vaginalis



Diagnosis of hydrocele :

Ultrasound for diagnosis and exclusion of important secondary
cause like testicular tumor



DDx : hernia

o To differentiate it from hernia :

 In hernia cough reflex is +ve . in hydrocele is - ve



In hernia we cant get above it. In hydrocele we can



translumination: -ve in the hernia . +ve in the
hydrocele

  Treatment  of hydrocele
o  mild …. Follow up
o  indication for surgery :distressing the patient or large

size…..hydrocelectomy

o if old pt. cant tolerate anesthesia ….aspiration

complication of aspiration

1.infection (pyocele)

2.recurrence

3. injury to vessels (heamatocele)

DDx of absent testis

1 . agenesis

2 . ectopic

3 . orcheoctomy

4. retractile testis

5 . undesending testis

Undesending testis

Due to arrest of the testis on its normal descending pathway

  intra. Abd.
  superfascial inguinal testis
  canalucular

Dx : US ….CT

The most accurate is laparoscopy in intra. Abd.

Rx : orcheopexy should be done before 1yr age

 Problems of undescending testis

1. liable for trauma

2. liable for torsion

3. liable for tumor

4. infertility

5. usually associated with hernia and other congenital anomalies

The indication of circumcision

1.relegiuos

2.repeated UTI

3.ca of prepuse

4.phemosis and paraphymosis (in paraphymosis need emergency
cercumcession)

 Complication of circumcision

1.bleeding (suture the art.)

2.injury (cut the glans with prepuce)

If we use cautery obliterate the art. And causing gangrene of the penis

3. Infection

 PHYMOSIS

narrowing of the prepuse opening, so its occur in
uncircumcised child
treatment is circumcision

 PARAPHYMOSIS

retraction of the prepuse behind the glance(so occur in

uncircumcised child also)  causing cut of blood supply to the
glance and gangrene of the glance  , so its emergency
condition

 MEATAL STENOSIS

narrowing of the the meatus in the glance ,its usually occur in
circumcised child causing severe narrowing or urinary stream
Treatment by enlargement of the meatus by dilatation or
meatotomy

Varicocele

Abnormal dilatation of pampiniform plexus of the testis

 Cause:

Malfunction of the valves mainly the left side

Varicocele cause local elevation of temperature that lead to
infertility



Presentation

incidentally

finding during examination of the testis

mild pain

infertility

 when u examine the pt. U should examine him in 2 position

(standing and setting )

 Valsalva manuver During examination it appear as a sac of

worm



Investigation

u.s , doppler u.s



Indication of surgery :

PAIN

testicular atrophy

infertility

young unmarried

treatment

---varicocelectomy by surgery (inguinal or

subinguinal approach), or by laparoscopy ,

Hydronephrosis

 is aseptic dilatation of pelvicalecial system (no infection. no

fever)

 hydronephrosis will cause pressure on the cortex and cause

gradual atrophy of the cortex and decrease in thr renal function
(thinning of the cortex ---less function )

  in hydeonephrosis
  if the cause is from the ureter –unilateral hydronephrosis
  if the cause in the bladder and urethra –bilateral hydronephrosis



Normal renal calyces shape is cup .. This mean normal cortical
thickness so normal function .. While clubbing shaped calyces mean
hydronephrosis ,thinned cortex so Decrease renal function

 Causes :

o Obstructive(intramural ,mural and extramural) usually the cause

can be diagnosed by ULS,IVU AND CT SCAN

o refluxive ( vesicouretral reflux )

In child with hydronephrosis you should exclude reflex by MCUG

Pregnancy also cause hydronephrosis

 most common cause of hydreonephrosis is

obstruction by calculi (stone)

Renal stone

Radioopaqe like calecium stone ,and radiolucent like uric acid which
occure in acidic urine
Staghorn stone which is called also infectious stone usually occur in
alkaline urine
Diagnosis bu ULS ,IVU AND CT Scan
Treatment of renal stone
1—conservative and follow up in stone less than 5 mm, this
includepain killer , antibiotic for infection and drink plenty of water
2— flexable ureteroscopy with lasser

3—ESWL ,for stone less than 2 C

Contraindication of ESWL:

 It cause bleeding so it contraindicated in patient with bleeding

tendency

 If we have obstruction distally
 pregnancy

4 – PCNL for stone more than  2 cm ,staghorn stone ,and stone in the
lower renal calyces
5—open  surgery  ,if  all  the  previous  options  is  not  suitable  or  not
available  ,this  include  puelolithotomy,nephrolithotomy  or  parial
nephrectomy, and even nephrectomy in non functioning kidney
6—  chemical  dissolution  of  stone  ,especially  in  uric  acid  stone  by
alkalization of urine by potassium citrate

URETERIC STONE TREATMENT OPTIONS

1—conservative ,like that of renal stone conservative treatment ,in
addition we can add alpha blocker (tamsulusin) which can aid the
passage of the stone ,this patient should be followed up ,if not respond
change to intervention options

indication of intervention

 Single kidney
 Fail of medical treatment

Hydronephrosis

2—ESWL for stone less than 1 cm
3—ureteroscope the most widely used options nowadays

4—open surgery (ureterolithotomy)

2. Surgery : indication



Single kidney



Fail of medical treatment

Hydronephrosis

Vesical stone
It may be primary like in poor children, or secondary to bladder outlet
obstruction(like BPH ) ,and also in neurogenic bladder
diagnosis usually by ULS AND KUB
either by open surgery  when the stone is large
or by endoscopic lithotripsy
when  the  stone  is  associated  with  BPH    ,both  conditions  should  be
treated at the same time

DOUBLE J STENT

Indications
1.  to bypass ureteric obstruction
2.  after  ureteroscopic  manipulation  (like    after  removal  of  ureteric
stone)
3.  after  ureteric  surgery  like  pyeloplasty  for  PUJ  obstruction, end  to
end  anastomosis  of  ureter  like  in  ureteric  injury  and  after
reimplantation of ureter for vesicoureteral reflux
4. after ureteric injury
5.  before  difficult  pelvic  surgery  like  hysterectomy  or  colectomy  to
avoid ureteric injury during surgery
6. before ESWL for renal stone in a single kidney

7. pregnancy with hydronephrosis
the hydronephrosis may be normal or pathological and we cant do
any investigation to confirm it because all test is contraindicated in
pregnancy . so we put the double J to be save until delivery

Complication

UTI, dysuria, ,frequency ,dislodgment of stent ,ureteric injury during
insertion of the stent incrustations on the stent and difficulty in
removing it when the stent stay for long duration

NEPHRECTOMY

 simple nephrectomy ,removal of the kidney alone ,usually non

functioning kidney due to benign conditions (less than 15
percent function by isotope renal scanning)

like in hydronephrosis ,renal stone ,renal hypoplasia

 radical nephrectomy ,removal of the kidney with surrounding

fat and gerota facia, this is usually done for renal cell carcinoma

bladder tumor

  mostly its transitional cell carcinoma
  smoking is important predisposing factor
  recurrent painless hematuria is the most common presentation

DIAGNOSIS

 ULS , AND CT SCANN FOR STSSGING OF THE TUMOR
 DIFINIT DIAGNOSIS IS BY CYSTOSCOPY AND BIOBSY

TREATMENT

 SUPERFACIAL BT (TA,T1)

Transurethral resection of the bladder tumor TUR BT ,with follow up
by cystoscopy every 3 months to detect any recurrence
If  the  tumor  is  large  or  multiple  or  high  grade  or  recurrent  or
involvement  of  lamina  propria  or  the  presence  of  carcinoma  insitu
with  bladder  tumor  this  patient  need  intravasical  chemotherapy
course (weekly for 6 weeks) in addition to TURBT and follow up

 DEEP BT (T2---T4) (tumor with muscle invasion)

RADICAL CYSTECTOMY WITH URINARY DIVERSION

PROSTATIC CARCINOMA

 localized carcinoma treated by radical prostatectomy
 metastatic tumor(which is most commonly to the bone) treated

by hormonal therapy by bilateral orchectomy or by antiandrogin
therapy