ESSAY PAST YEAR UROLOGY (by Melly)

TOPIC 1: BLADDER TUMOR

DIAGNOSIS
1) US : Echogenic intravesical mass
2) Plain & IVU : bladder filling defect
3) Pelvic & abdominal CT : confirm & stage
bladder tumors
4) Urine cytology
5) Cystoscopy & biopsy : proper staging,
degree of spread
6) Metastatic workup : x-ray chest & bone
scan
TREATMENT
a) Superficial bladder tumors (2006)(2008)
1) Endoscopic: Transurethral resection
(TURBT)
2) Immunotherapy: Intravesical
chemotherapy (BCG vaccine) 6
weekly instillations followed by
maintainance 3 weekly instillation
every 6 months
Aim :
i) Reduce tumor recurrence
ii) Avoid tumor progression
Indications in multiple, big, T1,
recurrent
3) Follow up : US, urine cytology,
cystoscopy, biopsy
4) Radical cystectomy (for NMIBC) : high
risk tumors resisting Rx & rapidly
recurrent

TOPIC 2: RENAL TUMORS

b) Rx of invasive tumors
1) Radical cystectomy (gold standard)
2) Radical radiotherapy (less efficient)
3) Bladder saving protocol
i) Responding tumor: Initial
chemotherapy followed by
radiotherapy
ii) Non-responding tumors : salvage
cystectomy

CLINICAL PICTURE OF RENAL CELL

CARCINOMA (2010)(2014)
SYMPTOMS
1) Asymptomatic - accidentalloma
2) Triad : pain, mass, hematuria
3) Varicocele
4) Paraneoplastic syndrome:
- Stauffer syd
- Hypercalcemia
- Hypertension
- Hormonal secretions
5) A renal swelling may be felt by the
patient.
6) Non-specific symptoms: anorexia,
nausea, vomiting,
7) Metastatic pains.
MANAGEMENT OF RENAL TUMORS
( 2008)(2013)
INVESTIGATIONS
a) Laboratory Finding:
1) Urine analysis:
Haematuria: gross or microscopic.
Proteinuria renal vein
thrombosis.
2) Blood picture: anaemia
b) Radiological Findings:
1) Plain X-Ray of UT
Enlarged soft tissue shadow of the
kidney.

Obliterated psoas line.

Calcifications 10%
2) IVU:
ii) A space occupying lesion
distorting &/or amputating the
calyces.
iii) In late cases no contrast
excretion ? renal vein
thrombosis.
3) Upper abd U/S
4) C.T. Scanning tumor staging
5) Arteriography vascularity of the
tumour
6) MRI
7) Screening for metastases:
X-Ray chest
Skeletal survey (osteolytic)

TREATMENT (RCC)
1) Radical nephrectomy locally
resectable
Indications: large tumor & central
position
2) Partial nephrectomy (small tumor &
periphery)
2) For inoperable cases : locally
irresectable or metastatic
i) Radiation therapy (no response).
ii) Hormonal therapy.
iii) Cytotoxic chemotherapy
iv)Immunotherapy

3) Nephron sparing Surgery (NSS) with

sparing margin

TOPIC 3: OBSTRUCTIVE
UROPATHY
TYPES OF URINARY RETENTION (2007)
(2010)
1.ACUTE URINARY RETENTION
Painful inability to void, with relief of pain
following drainage of the bladder by
catheterization
2.CHRONIC URINARY RETENTION
Obstruction develops slowly,bladder is
distended (stretched) very gradually over
weeks/months, pain is not a feature
CAUSES OF ACUTE URINARY
RETENTION (2) (2006)(2007)(2008)
(2010)
a) Men: (2005)
1)
Benign prostatic enlargement
(BPE) due to BPH
2)
Carcinoma of the prostate
3)
Urethral stricture
4)
Prostatic abscess
b) Women

1) Pelvic prolapse (cystocoele,

rectocoele, uterine)
2) Urethral stricture;
3) Urethral diverticulum;
4) Post surgery for stress
incontinence
5) pelvic masses (e.g., ovarian
masses)
c) Both Sex
1) Haematuria leading to clot retention
2) Drugs
3) Pain
4) Sacral nerve compression or
damage(cauda equina)
5) Radical pelvic surgery
6) Pelvic fracture rupturing the urethra
7) Neurotropic viruses involving the
sensory dorsal root ganglia of S2S4
(herpes simplex or zoster);
8) Multiple sclerosis
9) Transverse myelitis
10)Diabetic cystopathy
11)Damage to dorsal columns of spinal
cord causing loss of bladder
sensation (tabes dorsalis, pernicious
anaemia)
DIAGNOSIS OF ACUTE URINARY
RETENTION (2006)(2008)
a) History of difficulty or passage of stone
b) Clinically
1) Palpation & percussion of abd : full
tender bladder

2) DRE for prostatic enlargement, post

urethral stone
3) Genital exm for phimosis, caruncle
4) Neurological exm : flaccid anus,
diminishes /absent bulbocavernous
reflex, perianal hypoplasia
(neurogenic hyporeflex bladder)

b)

Late Management:
Treating the underlying cause

c) US : show full bladder

d) PXR : show stone in urethra / spina
bifida / sacral agenesis (neurogenic
bladder)
e) IVU : evaluate renal condition
(hydronephrosis) / full bladder in post
voiding film
f) Voiding cystourethrography : Dx post
urethral valve
g) Urethral calibration & urethrography :
Dx stricture
h) Urodynamic testing : suspected
neurogenic bladder

TREATMENT OF ACUTE URINARY

RETENTION (2004)(2016)(2008)(2009)
a) Initial Management :
1)
Urethral catheterisation
2)
Suprapubic catheter ( SPC)

HYDRONEPHROSIS (2012)
DEFINITION
Descriptive term refer to dilatation of
pelvis and calyces.
It can occur with or without obstruction.
CLINICAL DIAGNOSIS
Symptoms
Wide range: asymptomatic renal colic
Depending on:
i) Degree: complete or partial
ii) Time interval: acute or chronic
iii) Etiology: intrinsic Vs extrinsic
iv) Laterality: unilateral or bilateral
Signs
Wide range: no signs
1) Abdominal mass
2) Volume overload
3) Azotemia
MANAGEMENT

MANAGEMENT OF OBSTRUCTIVE
ANURIA (2009)(2013)
ANURIA vs RETENTION OF URINE
(2008)
ANURIA

URINE

Complete cessation

RETENTION
Inability to

of urine formation

DEFINITIO

evacuate

bladder
completely

GENERAL

Bad

CONDITIO

Good

Supravesical
obstruction
(bilateral/unilateral

Infravesical
MECHANIS
M

in solitary kidney)
1) No desire to
urinate
2) No pain or loin

CP

obstruction
1) BPH
2) Urethral
stricture
1) Desire to
urinate
2) Severe

pain

agonizing
suprapubic
pain
Full bladder

Empty bladder
EXAM

buldge)
1) Normal

1) Abnormal kidney
function tests
2) US :
hydronephrosis,

(suprapubic

kidney
IX

function tests
2) US : full

empty bladder
3) Catheter : no

bladder
3) Catheter :

urine
1) Urethral

urine pass
Evacuation of

catheterization
then remove

bladder by
Rx

urethral catheter

Fracture ribs
INVESTIGATION
1) Lab:
Urinalysis
Hematuria
Serial Hct value
2) Imaging:
CT abdomen & pelvis
IVU
US
Plain X ray chest & abd
MANAGEMENT
Emergency measure:
1) Rx of shock
2) Resuscitation
3) Evaluate associated injury

obstruction (Rx of
cause)
2) PCNL if stone

TOPIC 4: TRAUMA
1.RENAL TRAUMA(2012)(2013)
DIAGNOSIS
1)
Symptoms :
Flank pain
Hematuria
Abdominal distension, n&v
Abdominal swelling
Hypotension secondary to bleeding
2) Signs:
Shock, decrease bp
Ecchymosis of flank
Flank mass

Active observation (blunt trauma):

monitor bp, pulse rate, repeated hct
& imaging
Surgical exploration:
Absolute indication in life
threatening he & large expanding
pulsatile retroperitoneal hematoma
TREATMENT
1. Drainage
2. Suture tear, repair
3. Partial nephrectomy
4. nephrectomy
2.BLADDER RUPTURE
TYPES: (2009)
1) Intraperitoneal
2) Extra peritoneal
3) Combined

DIAGNOSIS (2007)(2008)(2009)(2013)
(2014)
a) History of trauma
b)
-

Symptoms :
Gross hematuria (82%)
Abdominal tenderness (62%)
Suprapubic bruises, ecchymosis,
coolness
Urinary extravasation (rupture)

c) Clinical examination
1) General : signs of shock
2) Abdominal exm :
Bruises in lower abdominal region
Abdominal tenderness or rigidity
(peritonitis)
Signs of pelvic fracture with
ecchymosis
Tenderness over pelvic bones
d) Laboratory investigations
Urine analysis : microscopic or gross
hematuria
e) Radiological diagnosis
1) Plain x-ray abdomen & pelvis (pelvic
fracture)
2) CT cystography
3) Ascending cystogram*
Shows extravasation of dye from
UB
i) In Intraperitoneal rupture of
dye seen extravasting in
whole abdomen

ii) In extraperitoneal rupture,

dye seen only around UB
TREATMENT (2007)(2008)(2009)(2013)
(2014)
1) Emergency measures & correction of
shock
2) Intraperitoneal (emergency)
- Immediate exploration
- Drainage & repair of tear
- Catheter (7-10 days)
3) extra peritoneal tears : (conservative)
- bladder drainage by catheter for 7 days
- antibiotic
- follow up for 10 days (imaging)

3.MANAGEMENT OF TRAUMATIC
RUPTURE OF POST-URETHRA (2005)
DIGNOSIS
1) History of trauma
2) Retention of urine
3) Lower abdominal pain
4) Bleeding at external urinary meatus
5) Signs of shock
6) Suprapubic tenderness with/out
contusions in lower abdomen &
perineum(ass bladder injury)
7) Rectal exam reveals prostatic
displacement in most cases
8) Urethral catheterization should be
avoided as it may
i aggravate urethral trauma
ii introduce infection into pelvic
hematoma

9) Retrograde urethrography is diagnostic :

shows extravasation of contrast into
perivesical space
TREATMENT
1) Resuscitation & management of
associated serious injuries
2) Suprapubic cystostomy in all avoid
opening tissue planes to evacuate
periprostatic hematoma
Suprapubic drainage is kept for 6
months combined antegrade cystourethrography (suprapubic cath)
The latter is managed either
i Endoscopically (visual internal
urethrotomy) or
ii Surgically ( bulboprostatic
anastomotic urethroplasty)

TOPIC 4: PROSTATE
MANAGEMENT OF BPH (2004)(2014)
INVESTIGATIONS
a) Uroflowmetry (simple & non invasive)
N max flow rate (Q-Max) : > 18 ml/sec
(if <10 ml/sec = obstruction or weak
detrusor ms
b)

Lab investigations
Urinalysis
Serum creatinine
Serum PSA

b) Imaging
1) Abdominal ultrasonography:

*size of gland, PVR, associated stone,

hydronephrosis,
2) KUB: radio-opaque calculi
3) Intravenous Urography:
secretory function of the kidney
basal smooth filling defect in the
bladder
4) Urethro-cystoscopy : in case of
hematuria
TREATMENT OF BPH
I) Non- symptomatic BPH : Reassurance,
Follow up
II) Symptomatic BPH:
a) Conservative Rx:medical treatment
1) 5- alpha - reductase inhibitors:
Doxazosin, Tamsolucin
2) Alpha adrenergic blockers:
Finastride, Dutastride
b) Surgical treatment:
1) Trans-urethral resection of the
prostate (TURP)
Gold standard 90% of cases
2) Open surgical prostatectomy
(enucleation adenectomy)
i) Very large BPH
ii) Concomitant bladder lesion
needs open surgery
iii) Patient limitation (limited hip
joint mobility)
INDICATION PROSTATECTOMY (2008)
1) Repeated AUR
2) Chronic UR

3)
4)
5)
6)

Severe obstructive symptoms

Failure of medical treatment
Haematuria
Complications : Rec. UTI,
Hydronephrosis, Bladder stones or
diverticula

COMPLICATIONS PROSTATECTOMY
(2008)
1. Comp of anesthesia
2. intra op :
a. bleeding
b. TUR syndrome
c. Trauma
3. Immediate post op:
d. Bleeding, primary reaction
e. Problem with catheter
f. Re-retention
4. Delayed post op:
a. Bleeding
b. Infection UTI
c. Urine leak, incontinence
d. Urethral stricture
PATHOLOGY OF PROSTATE CANCER
(2004)
Histopathology
1) Adenocarcinoma
More than 95%.
Arises from the epithelium of
prostatic acini or small peripheral
prostatic ducts
2) Transitional cell carcinoma
Less than 4%

v) Assessment of other abdominal

organs
b) MRI
c) Imaging of Skeletal metastasis
i) Bone scan (high sensitivity but
low specificity- high false +ve
result)
ii) Conventional Skeletal
radiography (low sensitivity but
high specificity)
iii) Bone CT

Arises from Prostatic urethra, central

prostatic ducts or direct extension
from TCC of the urinary bladder

DIAGNOSIS OF PROSTATE CANCER

(2012)
1) CP
2) Digital Rectal Examination (DRE)
An abnormal DRE is defined by :
i) Asymmetric enlargement of the
gland
ii) A prostatic nodule
iii) Firm to hard consistency
Only 50% of pts with abnormal DRE
prove to have prostate cancer
Normal DRE does not exclude cancer
3) Prostatic biopsy
Is essential for the diagnosis
Transrectal ultrasound guided
prostatic (TRUS) biopsy
Indications :
i) Elevated PSA
ii) Abnormal DRE
iii) Both
4) Imaging in the diagnosis of prostate
cancer
a) Ultrasonography abdominal or
trans- rectal
i) No specific sonographic pattern:
homogenous, heterogeneous,
iso, hypo, or hyper echoec
ii) Size of the gland
iii) Post void residual
iv) Effect on upper urinary tract

TOPIC 5: EMERGENCIES
MANAGEMENT OF TESTICULAR
TORSION ( 2007)(2014)
a) NEONATAL TESTICULAR TORSION
CLINICAL PICTURE
The infant is restless, reluctant to
feeding.
Hard, large scrotal mass, -ve
transillumination.

TREATMENT
It is controversial
1) No treatment the testis is already
necrotic.
2) Surgical orchiectomy with contralateral
orchipexy.
b) PUBERTAL TESTICULAR TORSION
(Intravaginal torsion)
CLINICAL PICTURE

Sudden onset of acute testicular

pain and swelling.

Severe tenderness.

Nausea and vomiting.

Transverse lie of the testis.

Scrotal elevation will increase pain.

Secondary hydrocele may develop.

Therapeutic goal: preserve renal fx, avoid

renal failure
30% at risk for progressive renal
insufficiency
DIAGNOSIS
a) Ultrasound
Key hole sign
Thick-walled distended bladder
b) VCUG (diagnostic test)
See bladder neck
Sudden cut off between narrow &
dilated part
With/out reflux
TREATMENT
1)
2)
3)
4)

Stabilize critically ill baby

Urethral feeding tube
Transurethral fulgration of valves
Vesicotomy if renal function is impaired

TOPIC 6: CONGENITAL
POSTERIOR URETHRAL VALVE (2014)
CLINICAL PRESENTATION
Bilateral flank masses (hydronephrosis)
Distended bladder
Poor urinary stream (+/- dribbling)
Diagnostic test: VCUG

TOPIC 7: UROLITHIASIS /
STONES
ETIOLOGY OF BLADDER STONES (2006)
1) Supersaturation of urine
Dt excessive excretion of poorly
soluble salts in urine

Eg : Ca, oxalate, phosphate, uric acid,

cysteine, xanthine

2) Deficiency of inhibitors of crystallization

Eg : Mg, pyrophosphate &/ citrates
3) Stasis along urinary tract
4) Infection
Shreads of pus may provide nucleus
upon which crystals may form
+ infection by urea splitting org as
proteus alkalinization of urine
encourage ppt of phosphates

COMPOSITION OF URINARY STONES

(2012)
1) Calcium stones
75% of UT calculi
Radio-opaque
Either :
i) Calcium oxalate
ii) Calcium phosphate
2) Uric acid stones
5-15% of UT calculi
Radio-lucent
3) Triple phosphate stones struvite=
staghorn
Formed of magnesium ammonium
phosphate (MAP)
4) Cystine stones
1% UT calculi
Faintly radio-opaque

Formed in acid urine (pts with

excessive excretion of cystine in
urine dt hereditary metabolic
abnormality)

MANAGEMENT OF UPPER URINARY

TRACT CALCULI
A. Diagnosis :CP
1. Pain : colicky, dull aching (stretch
capsule)
2. Hematuria
3. Irritative symptoms : urgency,
frequency, dysuria
4. Symptoms of comp : infection ,
obstruction
5. Obstructive anuria
B. Emergency treatment of
1) Renal (ureteric) colic
2) Obstructive (calculus) anuria
C. Treatment of stones (2004)(2006)(2007)
i) SIZE
- Small
- Large
ii) SITE:
- Ureter: ureteroscopy*,
ureterolithostomy
- Kidney: PCNL*, pyelolithotomy,
nephrolithotomy,
pyelonephrolithotomy, partialradical
nephrectomy
- Bladder: cystolithotripsy*,
cystolithotomy
- Urethra: push to bladder, meatotomy
iii) COMPOSITION

A) INVESTIGATIONS OF UROLITHIASIS
a) Laboratory:
1) Urine analysis
May show haematuria.
Pyuria and bacteruria are frequent.
The type of crystals present in the
urine may predict the composition
of the stone.
2) Blood urea & serum creatinine :
estimate of the total renal function.
b) Imaging :
1) X-rays
PXR of the abdomen : radio-opaque
calculi (80-90%)
To differentiate renal & gall bladder
stones :
i) A right lateral view when a radio-opaque
shadow(s) is shown in the right renal area.
ii) A renal calculus overlies the vertebral
bodies whereas gallstones are far anterior.
2) IVU is essential
A post-voiding film is essential to show
ureterovesical and intramural calculi.
3) Ultrasonography
Valuable in :
i) Pregnancy
ii) Anuric patients
iii) Allergic to the contrast material
It shows the acoustic shadow of the
stone, stasis or hydronephrosis are
also shown.

4) Non contrast spiral CT

Used in radiolucent stones or ureamic
patients
To show the site, size and +/- type of
stone
B) EMERGENCY TREATMENT
a) RENAL (URETERIC) COLIC:
1) Antispasmodics (e.g khelline,
buscopan, papaverine,) + pain killers
(e.g. voltaren, indocid,) IM +
diuretics
2) Opiates (only the exceptional case)
b) OBSTRUCTIVE (CALCULUS) ANURIA:
1) Short term conservative trial for 12
hours with diuretics (lasix 6 amp or
15% mannitol) + antispasmodics
2) A plain X-Ray and ultrasonography
show the obstructing stone(s) and
the condition of the kidneys.
3) Ureteric catheterization or JJ stent in
every case
4) Urinary diversion PCN above the
level of the obstruction is required
C) TREATMENT OF STONES

i) SMALL STONES less than 5mm in

diameter usually pass spontaneously
aided by adequate hydration:
+ Diuretics, e.g. thiazides one tablet
daily
+
Antispasmodics e.g. khelline products,
hyocine (buscopan) or papaverine(nospa) .
ii) LARGER RENAL & URETERIC STONES :
1) Extracorporeal shock wave
lithotripsy (ESWL)
suitable for stones < 2 cm in
diameter
not assc with distal
obstruction/active infection
2) Percutaneous nephrolithotomy
done under fluoroscopic (X-Ray)
control
suitable for most renal calculi
iii) SURGERY : the role of surgery is
declining
I) Rx of upper urinary calculi
a) FOR RENAL STONES
The kidney is exposed extraperitoneally by
a supracostal incision with the patient
lying in lateral position.
1) Pyelolithotomy
extraction of stone through an
incision in renal pelvis
the operation of choice

2) Nephrolithotomy
extraction of stone thr an incision in
renal parenchyma
suitable for some calyceal stones
which cannot be extracted via the
renal pelvis
3) Extended pyelolithotomy or pyelonephrolithotomy is indicated in
branched (staghorn) stones.
4) Partial Nephrectomy,
excision of the lower third of the
kidney
indicated in case of stone in the
lower calyx whose drainage is
defective
5) Nephrectomy
should be avoided even in mx of
staghorn stones
it is only done for a functionless
destroyed kidney, or as a life saving
measure because of intraoperative
bleeding during renal stone surgery

b) URETERAL STONES

Ureterolithotomy is indicated for

1) large stones
2) stones with distal stricture
3) after failure of endourologic
manipulations.

c) LOWER THIRD OF THE URETER

STONES suitable for ureteroscopic
manipulations including:
Disintegration of larger stones by US or
electrohydraulic waves or by the
pneumatic lithoclast or by Laser beam.
d) IMPACTED STONES IN THE
INTRAMURAL URETER
can be extracted cystoscopically after
transurethral incision of the sub mucosal
ureter (ureteral meatotomy).
II) Rx of lower urinary calculi
a) BLADDER STONES
Stone : cystolithotripsy
Stones : cystolithotomy
1) Single, medium sized stones (1-2 cm
in diameter)
Crushed by lithotrite (litholapaxy)
2) Large calculi
Manage by extraperitoneally
through suprapubic midline
incision (litholatomy)
b) URETHRAL CALCULI
1) Posterior urethral calculi are
cautiously pushed back by a urethral
sound or by a urethroscope to the
bladder to be treated as bladder
calculi.
2) Impacted stones at the fossa
navicularis can be extracted by doing

meatotomy of the external urinary

meatus.
3) Bulbar urethral stones can be
extracted through the perineum
(bulbar urethrolithotomy).
4) Stones in the penile urethra are
pushed back to the bulbar urethra
and treated as such

b)
TREATMENT
a) Manual detorsion (done from medial
to lateral)
Not recommended as it is not a final
solution , torsion:
i) may recur
ii) may be incomplete so the pain is
relieved but the testis is still
ischemic

Surgical exploration
1)
Affected testis
if viable detorsion and
orchiopexy
if not viable do orchiectomy.
2)
Contralateral testis
orchiopexy.