Urology Lecture

UROLOGYUROLOGY

PHYSICAL EXAMINATION PHYSICAL EXAMINATION OF THE GENITOURINARY OF THE GENITOURINARY

TRACTTRACT

Unusual findings on Unusual findings on general examinationgeneral examination

1.1. Gynecomastia:Gynecomastia:

a. estrogen treatment for a. estrogen treatment for prostateprostate

cancercancer

b. testicular cancerb. testicular cancer

c. adrenocortical hyperplasiac. adrenocortical hyperplasia

d. disease of the liverd. disease of the liver

Physical examinationPhysical examination

2. Hemihypertrophy:2. Hemihypertrophy:

a. Wilm’s tumora. Wilm’s tumor

b. adrenal tumorsb. adrenal tumors

c. Neuroblastomac. Neuroblastoma

3. Clues to renal anomalies- 3. Clues to renal anomalies-

a. lateral displacement of the a. lateral displacement of the nipples:nipples:

bilateral renal hypoplasiabilateral renal hypoplasia

Physical ExaminationPhysical Examination

4. Others: endocrinologic changes:4. Others: endocrinologic changes:

a. hypertrophy of the external a. hypertrophy of the external

genitaliagenitalia

b. hirsutismb. hirsutism

c. hypertensionc. hypertension

Physical examinationPhysical examination

Examination of the kidneys;Examination of the kidneys;

1. Inspection: masses/fullness1. Inspection: masses/fullness

-tumors-tumors

-infections-infections

2. Palpation: 2. Palpation:

-technique-technique

-finding: mass ; -finding: mass ; tendernesstenderness


3.percussion: -hydronephrosis3.percussion: -hydronephrosis

-tumors-tumors

-trauma-trauma

4. Auscultation: systolic bruit-4. Auscultation: systolic bruit-

aneurysmsaneurysms

Renal vs. Radicular painRenal vs. Radicular pain

Radicular pain: costovertebral and Radicular pain: costovertebral and subcostal subcostal

areas spreads along the areas spreads along the coursecourse

of the ureterof the ureter

Causes:Causes:

- poor posture- poor posture

- arthritic changes- arthritic changes

- intervertebral disc disease- intervertebral disc disease


The BladderThe Bladder

- in adults, at least 150 ml to be - in adults, at least 150 ml to be

percussiblepercussible

- the best way to detect if full-- the best way to detect if full-percussionpercussion

Male External GenitaliaMale External Genitalia

PenisPenis

1. Inspection: if uncircumcised, 1. Inspection: if uncircumcised, foreskinforeskin

should be retractedshould be retracted

a. tumors, balanitisa. tumors, balanitis

Poor bladder stream:Poor bladder stream:

-BPH or Prostate CA-BPH or Prostate CA

-posterior urethral valves in -posterior urethral valves in childrenchildren

-strictures-strictures

The meatus: bloody spotting- meatal The meatus: bloody spotting- meatal stenosis,stenosis,

tumorstumors

-hypospadias-hypospadias

-epispadias-epispadias

2. Palpation: Peyronie’s disease, 2. Palpation: Peyronie’s disease, strictures,strictures,

dischargesdischarges

Scrotum: - inflammatory changesScrotum: - inflammatory changes

- elephantiasis- elephantiasis

Testis:- a hard area should be regarded as Testis:- a hard area should be regarded as

malignant until proven otherwisemalignant until proven otherwise

Transillumination: hydrocele vs. solid Transillumination: hydrocele vs. solid massmass

Absent testis: cryptorchidism vs.retractile Absent testis: cryptorchidism vs.retractile

testistestis

Epididymis: induration- usually infectiousEpididymis: induration- usually infectious - malignant tumors - malignant tumors

areare exceedingly rareexceedingly rare

Spermatic cord: - swelling:cystic(hydrocele Spermatic cord: - swelling:cystic(hydrocele or hernia) vs, solid(tumors, lipoma)or hernia) vs, solid(tumors, lipoma)

-varicocele:dilated veins of -varicocele:dilated veins of the pampiniform plexus (“bag of worms”) the pampiniform plexus (“bag of worms”)

Vas DeferensVas Deferens

- thickening: chronic - thickening: chronic inflammationinflammation

- “beading” : TB- “beading” : TB

- absent (congenital)- absent (congenital)

Vaginal ExaminationVaginal Examination

-newborns and children: vaginal opening -newborns and children: vaginal opening

should be inspected for ashould be inspected for a

single opening(commonsingle opening(common

urogenital sinus), labial urogenital sinus), labial

fusion, split/hypertrophiedfusion, split/hypertrophied

clitorisclitoris

-urinary meatus:-urinary meatus:

- urethra caruncle: reddened, - urethra caruncle: reddened, tender, tender,

friable, lesionfriable, lesion

- urethral discharges: smears - urethral discharges: smears should beshould be

mademade

Rectal ExaminationRectal Examination

- laxity or spasticity: neurogenic - laxity or spasticity: neurogenic diseasedisease

- digital prostate exam- digital prostate exam

- rectal stenosis- rectal stenosis

- hemorrhoids, rectal fistulas- hemorrhoids, rectal fistulas

Lymph nodesLymph nodes

- in inflammatory lesions of the penis - in inflammatory lesions of the penis and and

scrotum (males) and vulva (females),scrotum (males) and vulva (females),

the inguinal and subinguinal LN’s may the inguinal and subinguinal LN’s may bebe

involvedinvolved

- malignant tumors of the penis, glans, - malignant tumors of the penis, glans, scrotalscrotal

skin, and distal urethra in womanskin, and distal urethra in woman

Neurologic ExamNeurologic Exam

- Bladder and urethral sphincters: S2 - Bladder and urethral sphincters: S2 – S4– S4

- anal sphincter tone- anal sphincter tone

- sensation of perianal skin- sensation of perianal skin

- eliciting Achilles tendon and - eliciting Achilles tendon and

bulbocavernous reflexbulbocavernous reflex

SYMPTOMS OF SYMPTOMS OF DISORDERS OF THE GU DISORDERS OF THE GU

TRACTTRACT

Symptoms of Disorders Symptoms of Disorders of the Genitourinary of the Genitourinary

TractTractSystemic manifestationsSystemic manifestations

- fever: e.g. acute pyelonephritis- fever: e.g. acute pyelonephritis

- weight loss: e.g. malignancy- weight loss: e.g. malignancy

- failure to thrive (children)e.g. - failure to thrive (children)e.g. chronicchronic

obstruction or UTI, or bothobstruction or UTI, or both

- general malaise: e.g. tumors, - general malaise: e.g. tumors, chronic chronic

pyelonephritis, renal failurepyelonephritis, renal failure

Local and referred painLocal and referred pain

Local pain: felt in or near an involved organ, Local pain: felt in or near an involved organ,

e.g. diseased kidney(T10-12,l1)-e.g. diseased kidney(T10-12,l1)-

felt in the CVA and flankfelt in the CVA and flank

Referred pain(more common): originates in aReferred pain(more common): originates in a

in a disease organ but is felt at in a disease organ but is felt at

some distance from that organ e.g.some distance from that organ e.g.

ureteral colic, acute cystitis ureteral colic, acute cystitis

Specific causes of painSpecific causes of pain

Kidney(Renal pain): dull and constant ache Kidney(Renal pain): dull and constant ache

in the CVA just lateral toin the CVA just lateral to

sacrospinalis muscle and sacrospinalis muscle and

just below the 12just below the 12thth rib e.g rib e.g

acute pyelonephritisacute pyelonephritis

Pseudorenal pain ( Radiculitis)Pseudorenal pain ( Radiculitis)

Ureteral pain (ureteral colic, renal colic): backUreteral pain (ureteral colic, renal colic): back pain from renal capsularpain from renal capsular distention combined with severe distention combined with severe colicky pain that radiates from colicky pain that radiates from the costovertebral angle down the costovertebral angle down towards the lower anterior towards the lower anterior abdominal quadrant, along the abdominal quadrant, along the

coursecourse of the ureterof the ureter

Vesical pain: overdistended bladder, Vesical pain: overdistended bladder, cystitis, cystitis,

bladder TB, schistomiasisbladder TB, schistomiasis

Prostate pain: vague discomfort of Prostate pain: vague discomfort of fullness infullness in

the perineal or rectal areathe perineal or rectal area

(S2-S4)(S2-S4)

Testicular pain: trauma infection, or torsion Testicular pain: trauma infection, or torsion ––

very severe, felt locally andvery severe, felt locally and

there may be radiation to there may be radiation to the the

lower abdomen.lower abdomen.

Epididymal pain: in acute epididymitis Epididymal pain: in acute epididymitis

Back and Leg pain: Back and Leg pain:

suggest metastases to the suggest metastases to the pelvicpelvic

bones (e.g. prostate bones (e.g. prostate cancer)cancer)

Gastrointestinal Gastrointestinal Symptoms of Urologic Symptoms of Urologic

DiseaseDisease

Ex. acute pyelonephritis, ureteral Ex. acute pyelonephritis, ureteral stonestone

Causes:Causes:

1. Renointestinal Reflexes1. Renointestinal Reflexes

2. Organ relationship2. Organ relationship

3. Peritoneal irritation3. Peritoneal irritation

Lower Urinary Tract Lower Urinary Tract SymptomsSymptoms

1. Urgency1. Urgency

2. Frequency2. Frequency

3. Nocturia3. Nocturia

4. Hesitancy4. Hesitancy

5. Intermittency5. Intermittency

6. Sensation of incomplete vioding6. Sensation of incomplete vioding

7. Decrease in the caliber and flow of 7. Decrease in the caliber and flow of thethe

urinary streamurinary stream

IncontinenceIncontinence

1. True (total) incontinence1. True (total) incontinence

2. Stress incontinence2. Stress incontinence

3. Paradoxic incontinence3. Paradoxic incontinence

4. Urge incontinence4. Urge incontinence

Oliguria and AnuriaOliguria and Anuria

PneumaturiaPneumaturia

Cloudy urineCloudy urine

RADIOLOGY OF THE RADIOLOGY OF THE URINARY TRACTURINARY TRACT

11. Intravenous urography. Intravenous urography

2. Retrograde Pyelography2. Retrograde Pyelography

3. Percutaneous Antegrade Urograms3. Percutaneous Antegrade Urograms

4. Cystography/ Voiding Cystograms4. Cystography/ Voiding Cystograms

5. Urethrography5. Urethrography

6. Vasography6. Vasography

7. Angiography7. Angiography

8. Sonography8. Sonography

9. Computed Tomography9. Computed Tomography

10. Magnetic Resonance Imaging10. Magnetic Resonance Imaging

URINARY URINARY OBSTRUCTION AND OBSTRUCTION AND

STASISSTASISClassified accdg.to:Classified accdg.to:

a. cause (congenital or acquired)a. cause (congenital or acquired)

b. duration (acute or chronic)b. duration (acute or chronic)

c. degree (complete or partial)c. degree (complete or partial)

d. level (upper,middle, or lower)d. level (upper,middle, or lower)

EtiologyEtiology

1. Congenital - meatal stenosis,ectopic1. Congenital - meatal stenosis,ectopic

ureters,posterior urethralureters,posterior urethral

valvesvalves

2. Acquired – urethral strictures,BPH,2. Acquired – urethral strictures,BPH,

Prostatic CA,bladder tumor,Prostatic CA,bladder tumor,

ureteral ureteral stones,retroperitonealstones,retroperitoneal

fibrosis,pregnancyfibrosis,pregnancy

Pathogenes and Pathogenes and Pathology:Pathology:

1. Lower Tract (urethral strictures)1. Lower Tract (urethral strictures)

2. Mid-tract (BPH)2. Mid-tract (BPH)

a. trabeculation of the bladder a. trabeculation of the bladder wallwall

b. cellulesb. cellules

c. diverticulac. diverticula

Upper TractUpper Tract

a. uretera. ureter

b. kidneysb. kidneys

Clinical findings:Clinical findings:

A. SymptomsA. Symptoms

1. Lower and mid tract1. Lower and mid tract

2. Upper tract2. Upper tract

B. SignsB. Signs

1. Lower and mid tract1. Lower and mid tract

2. Upper tract2. Upper tract

Laboratory findings:Laboratory findings:

11. Anemia. Anemia

2. Leucocytosis2. Leucocytosis

3. Urinalysis results3. Urinalysis results

4. Blood chemistry ( BUN and Serum 4. Blood chemistry ( BUN and Serum

creatinine)creatinine)

Ancillary proceduresAncillary procedures

1. Xray findings (e.g. Plain film, IVP)1. Xray findings (e.g. Plain film, IVP)

2. Isotope scanning2. Isotope scanning

3. Instrumental examination3. Instrumental examination

4. Interventional uroradiology4. Interventional uroradiology

ComplicationsComplications

1. Infection1. Infection

2. Precipitation of salts - stone 2. Precipitation of salts - stone formationformation

3. Compromise in renal function3. Compromise in renal function

TreatmentTreatment

A. Relief of ObstructionA. Relief of Obstruction

1. Lower and midtract obstruction1. Lower and midtract obstruction

2. Upper tract obstruction2. Upper tract obstruction

B. Eradication of InfectionB. Eradication of Infection

URINARY STONE URINARY STONE DISEASEDISEASE

EtiologyEtiology

1. Crystal component1. Crystal component

2. Matrix component2. Matrix component

Urinary IonsUrinary Ions

1. Calcium 1. Calcium

2. Oxalate 2. Oxalate

3. Phosphate3. Phosphate

4. Uric acid4. Uric acid

5. Sodium5. Sodium

6. Citrate6. Citrate

7. Magnesium7. Magnesium

8. Sulfate8. Sulfate

Stones varietiesStones varieties

A. Calcium calculiA. Calcium calculi

1. Absortive hypercalciuric nephrolithiasis1. Absortive hypercalciuric nephrolithiasis

2. Resorptive hypercalciuric nephrolithiasis2. Resorptive hypercalciuric nephrolithiasis

3. Renal hypercalciuria3. Renal hypercalciuria

4. Hyperuricosuric calcium nephrolithiasis4. Hyperuricosuric calcium nephrolithiasis

5. Hyperoxaluric calcium neprolithiasis5. Hyperoxaluric calcium neprolithiasis

6. Hypercitraturic calcium nephrolithiasis 6. Hypercitraturic calcium nephrolithiasis

B. Noncalcium calculiB. Noncalcium calculi

1. Struvite stones1. Struvite stones

2. Uric acid stones2. Uric acid stones

3. Cystine stones3. Cystine stones

4. Xanthine stones4. Xanthine stones

Symptoms and Signs at Symptoms and Signs at PresentationPresentation

1. Pain1. Pain

2. Hematuria2. Hematuria

3. Infection3. Infection

4. Fever4. Fever

5. Nausea and Vomiting5. Nausea and Vomiting

6. Asymptomatic6. Asymptomatic

Risk factorsRisk factors

1. Crystalluria 1. Crystalluria

2. Socioeconomic factors2. Socioeconomic factors

3. Diet 3. Diet

4. Occupation4. Occupation

5. Climate5. Climate

6. Family History6. Family History

7. Medications7. Medications

e.g. long term use of e.g. long term use of antacids, antacids,

triamterene, carbonic triamterene, carbonic anhydrase anhydrase

inhibitorsinhibitors

Radiologic investigationRadiologic investigation

1. IVP1. IVP

2. Tomography2. Tomography

3. KUB films and sonography3. KUB films and sonography

4. Retrograde Pyelography4. Retrograde Pyelography

5. CT scan5. CT scan

6. MRI6. MRI

7. Nuclear scintigraphy7. Nuclear scintigraphy

InterventionIntervention

11. Observation . Observation

2. Dissolution agents 2. Dissolution agents

3. Relief of obstruction3. Relief of obstruction

4. Extracorporeal Shock Wave 4. Extracorporeal Shock Wave LithotripsyLithotripsy

(ESWL)(ESWL)

5. Ureterospic stone extraction5. Ureterospic stone extraction

6. Percutaneous nephrolithotomy (PCNL)6. Percutaneous nephrolithotomy (PCNL)

7. Open stone surgery7. Open stone surgery

a. Pyelolithotomya. Pyelolithotomy

b. Anatropic nephrolithotomyb. Anatropic nephrolithotomy

PreventionPrevention

1. Metabolic evaluation1. Metabolic evaluation

2. Oral medications2. Oral medications

1. Alkalinizing agents1. Alkalinizing agents

2. Gastrointestinal absorption 2. Gastrointestinal absorption inhibitorinhibitor

3. Phosphate supplementation3. Phosphate supplementation

4. Diuretics4. Diuretics

5. Urease inhibitors5. Urease inhibitors

6. Uric acid lowering medications6. Uric acid lowering medications

UROTHELIAL UROTHELIAL CARCINOMASCARCINOMAS

BLADDER CARCINOMASBLADDER CARCINOMAS

Incidence:Incidence:

Male:female ratio (2.7:1)Male:female ratio (2.7:1)

Average age at diagnosis: 65 Average age at diagnosis: 65

Risk factorsRisk factors

1. Cigarette smoking1. Cigarette smoking

2. Occupational exposures (chemical, 2. Occupational exposures (chemical, dye,dye,

rubber, petroleum, leather, rubber, petroleum, leather, printing)printing)

3. cyclophosphamide3. cyclophosphamide

Types:Types:

1. Transitional Cell carcinomas - 1. Transitional Cell carcinomas - comprise comprise

90% of all bladder cancers90% of all bladder cancers

2. Adenocarcinomas - <2% of all bladder 2. Adenocarcinomas - <2% of all bladder

cancerscancers

3. Squamous cell carcinomas - 5-10%3. Squamous cell carcinomas - 5-10%

4. Undifferentiated CA4. Undifferentiated CA

5.Mixed CA5.Mixed CA

Clinical findingsClinical findings


1. Hematuria- 85-90% of patients with 1. Hematuria- 85-90% of patients with

bladder CAbladder CA

2. Irritability2. Irritability

3. Frequency3. Frequency

4. Dysuria4. Dysuria

5. Advanced disease-bone pain or flank 5. Advanced disease-bone pain or flank painpain

B. SignsB. Signs

1. Mass1. Mass

2. Hepatomegaly2. Hepatomegaly

3. Supraclavicular 3. Supraclavicular lymphadenopathylymphadenopathy

LaboratoriesLaboratories

1.1. Urinalysis Urinalysis

2. Hemogram2. Hemogram

3. Urinary cytology and flow 3. Urinary cytology and flow cytometrycytometry

4. Cell surface antigens4. Cell surface antigens

ImagingImaging

1. Sonography1. Sonography

2. IVP2. IVP

3. CT Scan3. CT Scan

4. MRI4. MRI

TreatmentTreatment

1. Cystourethroscopy and Tumor 1. Cystourethroscopy and Tumor resectionresection

2. Intravesical Chemotherapy2. Intravesical Chemotherapy

a. Mitomycina. Mitomycin

b. Thiotepab. Thiotepa

c. Doxorubicinc. Doxorubicin

d. BCGd. BCG

3.Open surgery3.Open surgery

a. Partial cystectomya. Partial cystectomy

b. Radical cystectomyb. Radical cystectomy

4. Radiotherapy4. Radiotherapy

5. Systemic Chemotherapy (MVAC)5. Systemic Chemotherapy (MVAC)

URETERAL AND RENAL URETERAL AND RENAL PELVIC CANCERSPELVIC CANCERS

Ratio of bladder: Renal pelvic : Ureteral Ratio of bladder: Renal pelvic : Ureteral

cancers – 51:3:1cancers – 51:3:1

Mean age at diagnosis : 65y/oMean age at diagnosis : 65y/o

Male:Female ratio – 2-4:1Male:Female ratio – 2-4:1

Risk of developing bladder CA : 30-50%Risk of developing bladder CA : 30-50%

Risk of developing upper tract CA : 2-4%Risk of developing upper tract CA : 2-4%

Patients with bladder CA have a <2% risk of Patients with bladder CA have a <2% risk of

developing upper tract CA’s developing upper tract CA’s

Etiology/Risk factors:Etiology/Risk factors:

1. Smoking1. Smoking

2. Exposure to industrial dyes or 2. Exposure to industrial dyes or solventssolvents

3. Long history of analgesic intake3. Long history of analgesic intake

4. Balkan nephropathy4. Balkan nephropathy

5. Aspirin, caffeine, and phenacetin5. Aspirin, caffeine, and phenacetin

Pathology:Pathology:

Majority(90-97%) are Transitional Cell Majority(90-97%) are Transitional Cell

CarcinomasCarcinomas

Squamous cell CA account for 10%Squamous cell CA account for 10%

Most are localized at the time of diagnosisMost are localized at the time of diagnosis

Most common metastatic sites: regionalMost common metastatic sites: regional

lymph nodes,bones, and lunglymph nodes,bones, and lung

Benign tumors: fibroepithelial polyp(most Benign tumors: fibroepithelial polyp(most

common),leiomyomas and common),leiomyomas and angiomasangiomas

Most common malignant mesodermal Most common malignant mesodermal

tumor: leiomyosarcomastumor: leiomyosarcomas

Clinical FindingsClinical Findings

Gross hematuria (70-90%)Gross hematuria (70-90%)

Flank pain (8-50%)Flank pain (8-50%)

Irritative voiding symptoms (5-10%)Irritative voiding symptoms (5-10%)

Flank mass (10-20%)Flank mass (10-20%)

Supraclavicular of inguinal Supraclavicular of inguinal lymhadenopathylymhadenopathy

LaboratoryLaboratory

Hematuria ( may be intermittent)Hematuria ( may be intermittent)

Liver function testLiver function test

Pyuria and bacteriuria – patients with Pyuria and bacteriuria – patients with

concomitant concomitant UTIUTI

Barbotage – exfoliated cellsBarbotage – exfoliated cells

Ureteral brush – increases diagnostic Ureteral brush – increases diagnostic

accuracyaccuracy

ImagingImaging

1. IVP1. IVP

2. CT Scan2. CT Scan

3. MRI3. MRI

Endoscopic proceduresEndoscopic procedures

UreteropyeloscopyUreteropyeloscopy

TreatmentTreatment

11. Surgery (nephroureterectomy) : . Surgery (nephroureterectomy) : standardstandard

therapytherapy

2. Chemotherapy (BCG, mitomycin) 2. Chemotherapy (BCG, mitomycin)

3. Radiotherapy : limited role3. Radiotherapy : limited role

GENITAL TUMORSGENITAL TUMORS

Tumors of the TestisTumors of the Testis

A. Germ Cell Tumors ( 90-95% )A. Germ Cell Tumors ( 90-95% )

B. Non-germ cell tumorsB. Non-germ cell tumors

C. Secondary tumorsC. Secondary tumors

Germ Cell TumorsGerm Cell Tumors

Epidemiology and Risk factorsEpidemiology and Risk factors

- 2-3 new cases per 100,000 males- 2-3 new cases per 100,000 males

- 1-2% billateral- 1-2% billateral

- 7-10% develop in men with hx of cryptorchidism- 7-10% develop in men with hx of cryptorchidism

- abdominal testis (risk of malignancy 1 in 20)- abdominal testis (risk of malignancy 1 in 20)

- inguinal testis (risk of malignancy is 1 in 50)- inguinal testis (risk of malignancy is 1 in 50)

- estrogen administration to the mother during- estrogen administration to the mother during

pregnancypregnancy

Two types of germ cell Two types of germ cell tumors:tumors:

A. Seminomatous ( seminoma)A. Seminomatous ( seminoma)

B. Non-seminomatousB. Non-seminomatous

1. Embryonal carcinoma1. Embryonal carcinoma

a. adult typea. adult type

b. yolk sac tumorsb. yolk sac tumors

2. Teratoma2. Teratoma

3. Choriocarcinoma3. Choriocarcinoma

Seminoma (most common overall)Seminoma (most common overall)

- 3 types- 3 types

1. Classic1. Classic

2. Anaplastic2. Anaplastic

3. Spermatocytic3. Spermatocytic

Patterns of spreadPatterns of spread

- typically spreads in a stepwise - typically spreads in a stepwise lymphaticlymphatic

fashion, except choriocarcinomafashion, except choriocarcinoma

- LN’s extend from T1 – L4- LN’s extend from T1 – L4

Primary landing sites:Primary landing sites:

Left testis - paraaortic area at the Left testis - paraaortic area at the level of level of

left renal hilumleft renal hilum

Right testis – interaortocaval area at Right testis – interaortocaval area at the the

level of right renal level of right renal hilumhilum



- painless enlargement- painless enlargement

- acute pain ( 10% )- acute pain ( 10% )

- back pain- back pain

- dyspnea- dyspnea

- cough- cough

- bone pain- bone pain

- asymptomatic ( 10% )- asymptomatic ( 10% )

B. SignsB. Signs

- mass / diffuse enlargement- mass / diffuse enlargement

- examination of the abdomen- examination of the abdomen

- supraclavicular nodes / inguinal - supraclavicular nodes / inguinal nodesnodes

- gynecomastia- gynecomastia

Tumor markers:Tumor markers:

1. AFP1. AFP

2. hCG2. hCG

3. LDH3. LDH

4. PLAP4. PLAP

5. Gamma glutamyl 5. Gamma glutamyl transpeptidasetranspeptidase

Incidence of elevated Incidence of elevated tumor markerstumor markers

hCG(%) AFP(%)hCG(%) AFP(%)

Seminoma 7 0Seminoma 7 0

Teratoma 25 38Teratoma 25 38

Teratocarcinoma 57 64Teratocarcinoma 57 64

Embryonal 60 70Embryonal 60 70

Choriocacinoma 100 0Choriocacinoma 100 0

Laboratories:Laboratories:

Liver function testsLiver function tests

HemogramHemogram

Assessment of renal function – for Assessment of renal function – for chemotherapychemotherapy

ImagingImaging

1. Scrotal ultrasonography1. Scrotal ultrasonography

2. Chest radiographs2. Chest radiographs

3. Abdominal CT scan3. Abdominal CT scan

Differential DxDifferential Dx

1. Epidydimitis/epidimoorchitis – most 1. Epidydimitis/epidimoorchitis – most commoncommon

2. Hydrocele2. Hydrocele

3. Spermatocele3. Spermatocele

4. Hematocele4. Hematocele

5. Granulomatous orchitis5. Granulomatous orchitis

6. Varicocele6. Varicocele

7. Epidermoid cyst 7. Epidermoid cyst

Staging:Staging:

Stage I – confined to the testisStage I – confined to the testis

Stage IIA - <2cm retroperitoneal lymphStage IIA - <2cm retroperitoneal lymph

node involvementnode involvement

Stage IIA - >2cm retroperitoneal lymphStage IIA - >2cm retroperitoneal lymph

node involvementnode involvement

Stage III - supradiaphragmatic nodal Stage III - supradiaphragmatic nodal involveinvolve

ment or visceral involvementment or visceral involvement

TreatmentTreatment

1. Radical Orchiectomy (inguinal approach)1. Radical Orchiectomy (inguinal approach)

Scrotal approach – to be avoidedScrotal approach – to be avoided

SeminomaSeminoma A. Low stage ( I, IIA )A. Low stage ( I, IIA )

- 95% are cured with radical - 95% are cured with radical orchiectomyorchiectomy

and retroperitoneal irradiationand retroperitoneal irradiation

((2500-3000 cGY)((2500-3000 cGY)

Low volume retroperitoneal dse. – Low volume retroperitoneal dse. – 87% 5yr.87% 5yr.

Survival rateSurvival rate

Prophylactic mediastinal irradiation – Prophylactic mediastinal irradiation – no no

longer employedlonger employed

B. High Stage Seminoma ( IIB,III )B. High Stage Seminoma ( IIB,III )

Radical Orchiectomy plus Primary Radical Orchiectomy plus Primary

ChemotherapyChemotherapy

Primary chemotherapy – platinum Primary chemotherapy – platinum basedbased

- PVB- PVB

- VAB- VAB

Nonseminomatous Germ Nonseminomatous Germ Cell Tumors (NSGCT)Cell Tumors (NSGCT)

A. Low Stage NSGCTA. Low Stage NSGCT Radical orchiectomy plus:Radical orchiectomy plus: 1. Retroperitoneal Lymph Node Dissection1. Retroperitoneal Lymph Node Dissection (RPLND)(RPLND) 2. Modified RPLND2. Modified RPLND 3. Surveillance (MSKCC):3. Surveillance (MSKCC): 1. Confined within the tunica albuginea1. Confined within the tunica albuginea 2. Does not demonstrate vascular 2. Does not demonstrate vascular

invasioninvasion 3. Tumor markers normalize after 3. Tumor markers normalize after

orchiectomy orchiectomy

4. Imaging does not show evidence of 4. Imaging does not show evidence of

diseasedisease

5. Reliable patient5. Reliable patient

Surveillance:Surveillance:

Followed monthly for the first two years Followed monthly for the first two years

and bimonthly in the third year.and bimonthly in the third year.

Tumors markers are obtained in each visitTumors markers are obtained in each visit

and imaging studies obtained every 3-4 and imaging studies obtained every 3-4 months. months.

Relapses: majority are within the 8 –10Relapses: majority are within the 8 –10 months.months.

C. High Stage Nonseminomatous C. High Stage Nonseminomatous germ Cell germ Cell

Tumors:Tumors: Radical orchiectomy plus primary Radical orchiectomy plus primary

chemotherapychemotherapy If after chemotherapy, tumor markers If after chemotherapy, tumor markers

normalize and a residual tumor is apparent normalize and a residual tumor is apparent on imaging studies,resection of that mass is on imaging studies,resection of that mass is necessary, because: necessary, because:

a. 20% of the time, it will harbor residual a. 20% of the time, it will harbor residual

cancercancer

b. 40% of the time, it will be teratomab. 40% of the time, it will be teratoma

c. 40% of the time, it will be fibrosisc. 40% of the time, it will be fibrosis

If after chemotherapy, tumor markers do notIf after chemotherapy, tumor markers do not

normalize,normalize,

Salvage chemotherapy is required ( cisplatin,Salvage chemotherapy is required ( cisplatin,

etoposide, bleomycin, efosfamide )etoposide, bleomycin, efosfamide )

Follow up after RPLND or radiotherapy:Follow up after RPLND or radiotherapy: Every 3 months for the first two Every 3 months for the first two

years,years, Every 6 monyhs until 5 years,Every 6 monyhs until 5 years, YearlyYearlyFor each visit,For each visit, PE of the remaining testis, the PE of the remaining testis, the

abdomenabdomen and lymph node areasand lymph node areas AFP, hCG, DH levels; Chest Xray AFP, hCG, DH levels; Chest Xray

Prognosis:Prognosis:

Stage I – 98% 5 year disease-freeStage I – 98% 5 year disease-free

survival survival

Stage II – 95% 5 year disease-Stage II – 95% 5 year disease-free free

survivalsurvival

Stage III- 35-75% 5 year disease-Stage III- 35-75% 5 year disease-free free

survival survival

Non germ cell tumors of Non germ cell tumors of the testisthe testis

11. Leydig cell tumors. Leydig cell tumors

2. Sertoli cell tumors2. Sertoli cell tumors

3. Gonadoblastoma3. Gonadoblastoma

Leydig cell tumorsLeydig cell tumors

- most common non-germ cell tumor - most common non-germ cell tumor of theof the

testistestis

Bimodal distribution: 5-9 year oldBimodal distribution: 5-9 year old

25-35 year old25-35 year old

- unlike germ cell tumors, there is no - unlike germ cell tumors, there is no

association with cryptorchidismassociation with cryptorchidism

Presentation:Presentation:

- prepubertal children - prepubertal children present with present with

virilizationvirilization

- 20-25% of adults with these - 20-25% of adults with these tumors tumors

have gynecomastiahave gynecomastia

- 10% are malignant- 10% are malignant

Laboratory:Laboratory: -elevated serum and urinary ketosteroids-elevated serum and urinary ketosteroids (elevations of 10-30X normal are typical(elevations of 10-30X normal are typical of malignancy)of malignancy) - elevated estrogens- elevated estrogensTreatmentTreatment 1. Radical orchiectomy- initial form of 1. Radical orchiectomy- initial form of treatmenttreatment 2. RPLND2. RPLND

4. Chemotherapy and radiotherapy - not 4. Chemotherapy and radiotherapy - not clearly defined rolesclearly defined roles

2. Sertoli cell tumors2. Sertoli cell tumors - exceedingly rareexceedingly rare - Bimodal distribution: 1 year old or - Bimodal distribution: 1 year old or

youngeryounger - 10% are malignant- 10% are malignant - virilization in children- virilization in children - gynecomastia (30%) in adults- gynecomastia (30%) in adults

- Radical orchiectomy – initial - Radical orchiectomy – initial treatmenttreatment

- RPLND indicated in malignant - RPLND indicated in malignant tumorstumors

- role of chemotherapy and - role of chemotherapy and radiotherapyradiotherapy

remain unclearremain unclear

3. Gonadoblastomas:3. Gonadoblastomas: - almost exclusively seen if patient with- almost exclusively seen if patient with gonadal dysgenesisgonadal dysgenesis - majority are under 30 y/o- majority are under 30 y/o - 4/5 of patients with - 4/5 of patients with

gonadoblastomas aregonadoblastomas are phenotypic femalesphenotypic females - males typically have cryptorchidism - males typically have cryptorchidism

or or hypospadiashypospadias

- radical orchiectomy – primary treatment ofradical orchiectomy – primary treatment of

choice choice - in the presence of gonadal dysgenesis, ain the presence of gonadal dysgenesis, a

contralateral gonadectomycontralateral gonadectomy

is indicated because the is indicated because the

tumors tends to be tumors tends to be bilateralbilateral

in 50% of casesin 50% of cases

Secondary tumors of the Secondary tumors of the testistestis

1. 1. LymphomaLymphoma- the most common testicular- the most common testicular tumors in a patient over the tumors in a patient over the age of 50.age of 50. - most common - most common

secondarysecondary neoplasm of the testisneoplasm of the testis

Seen in 3 clinical settings:Seen in 3 clinical settings:

a. late manifestation of widespread a. late manifestation of widespread manifistationmanifistation

b. initial manifestation of clinically occult b. initial manifestation of clinically occult diseasedisease

c. primary extranodal diseasec. primary extranodal disease

- painless enlargement- painless enlargement

- generalized constitutional symptoms- generalized constitutional symptoms

- 50% bilaterality- 50% bilaterality

Radical orchiectomy – to confirm the diagnosisRadical orchiectomy – to confirm the diagnosis -treatment is for the systemic disease-treatment is for the systemic disease - prognosis depends on the stage of the disease.- prognosis depends on the stage of the disease.

2. Leukemic infiltration of the testis2. Leukemic infiltration of the testis - the testis is a common site of relapse for - the testis is a common site of relapse for

children children with acute lymphocytic leukemia.with acute lymphocytic leukemia. - 50% bilateral involvement- 50% bilateral involvement - testis biopsy rather than orchiectomy is the - testis biopsy rather than orchiectomy is the

diag-diagnostic procedure of choice.nostic procedure of choice.

Treatment of choice:Treatment of choice:

1. Testicular irradiation1. Testicular irradiation 2. Adjuvant chemotherapy2. Adjuvant chemotherapy3. Metastatic tumors:3. Metastatic tumors: 1. Prostate – most common primary1. Prostate – most common primary 2. Lung2. Lung 3. GI tract3. GI tract 4. Melanoma4. Melanoma 5. kidney5. kidney

RENAL PARENCHYMAL RENAL PARENCHYMAL NEOPLASMSNEOPLASMS

Benign tumorsBenign tumors

1. Adenomas1. Adenomas – most common benign – most common benign tumor lesionstumor lesions

2. Oncocytoma2. Oncocytoma -high grade oncocytomas may be -high grade oncocytomas may be

intermixed with elements of RCC intermixed with elements of RCC

and can be found as co-existing and can be found as co-existing elements elements

with the same or opposite kidney. with the same or opposite kidney.

3.Angiomyolipoma ( Renal hamatoma)3.Angiomyolipoma ( Renal hamatoma) - found in 45-80% of patients with - found in 45-80% of patients with tuberous sclerosistuberous sclerosis - histologic components: mature fat cell,- histologic components: mature fat cell, smooth muscles, and blood vesselssmooth muscles, and blood vessels - severe bleeding may occur- severe bleeding may occur

4. Others4. Others: leiomyomas, hemagiomas, lipomas,: leiomyomas, hemagiomas, lipomas, juxtaglomerular cell tumorsjuxtaglomerular cell tumors

Renal Cell Carcinoma (Adenocarcinoma Renal Cell Carcinoma (Adenocarcinoma ofof

the Kidney)the Kidney) -account for 35 of adult cancer and-account for 35 of adult cancer and

85% of all primary malignant85% of all primary malignant

renal tumorsrenal tumors

- 5- 5thth to 6 to 6thth decade decade

Other terms: hypernephroma, clear cell Other terms: hypernephroma, clear cell carcinomas, carcinomas,

alveolar carcinomasalveolar carcinomas

Etiology/Risk factorsEtiology/Risk factors

Von Hippel Lindau DiseaseVon Hippel Lindau Disease Horseshoe kidneyHorseshoe kidney Adult polycystic kidney diseaseAdult polycystic kidney disease Acquired renal cystic disease (4-9% of Acquired renal cystic disease (4-9% of patients with ACDK)patients with ACDK) Cigarette smokingCigarette smoking Analgesic abuseAnalgesic abuse Shoe workers, leather tanners, asbestos, Shoe workers, leather tanners, asbestos, petroleum productspetroleum products

PathologyPathology

originates from the proximal renal originates from the proximal renal tubulartubular

epithelium equal frequency in both epithelium equal frequency in both

kidneyskidneys

Types:Types:

1. Clear cell type1. Clear cell type

2. Granular cell type2. Granular cell type

3. Mixed cell type3. Mixed cell type

PathogenesisPathogenesis

vascular tumors that spread either by vascular tumors that spread either by

direct invasion through the capsule into direct invasion through the capsule into

the perinephric fat and adjacent visceral the perinephric fat and adjacent visceral

structures or by direct extension into structures or by direct extension into

the renal vein \the renal vein \

most common site of mets : most common site of mets : lunglung


A.A. Symptoms and SignsSymptoms and Signs Classic triad: gross hematuria, flank Classic triad: gross hematuria, flank

pain,pain, and palpable mass and palpable mass (10 – 15% of patients)(10 – 15% of patients) Hematuria (gross or microscopic) – 60%Hematuria (gross or microscopic) – 60% Pain/abdominal mass – 40%Pain/abdominal mass – 40% Dyspnea/cough/bone pain – Dyspnea/cough/bone pain –

manifestationsmanifestations of metsof mets

B. Paraneoplastic syndromeB. Paraneoplastic syndrome 1. Erythtrocytosis1. Erythtrocytosis 2. Hypercalcemia2. Hypercalcemia 3. Hypertension3. Hypertension 4. Stauffer’s syndrome4. Stauffer’s syndromeLaboratoryLaboratory UrinalysisUrinalysis CBCCBC Blood chemistryBlood chemistry

ImagingImaging

UltrasoundUltrasound Excretory urography Excretory urography CT ScanningCT Scanning MRIMRI Renal angiographyRenal angiography Radionuclide imagingRadionuclide imaging

Fine needle aspirationFine needle aspirationInstrument and Cystologic examination Instrument and Cystologic examination

TreatmentTreatment A. Localized diseaseA. Localized disease Radical nephrectomyRadical nephrectomy

C. Disseminated DiseaseC. Disseminated Disease Adjunctive nephrectomyAdjunctive nephrectomy Paliative nephrectomyPaliative nephrectomy

Chemo / ImmunotherapyChemo / Immunotherapy

Radiation therapyRadiation therapy

Spontaneous RegressionSpontaneous Regression

PrognosisPrognosis

NEUROMUSCULAR NEUROMUSCULAR DYSFUNCTION OF THE DYSFUNCTION OF THE

LOWER URINARY TRACTLOWER URINARY TRACTDisease above the brain stemDisease above the brain stem

1. CVA 1. CVA

2. Dementia2. Dementia

3. Concussion3. Concussion

4. Brain tumors4. Brain tumors

5. Hydrocephalus5. Hydrocephalus

6. Cerebral Palsy6. Cerebral Palsy

7. Parkinson’s Disease7. Parkinson’s Disease

Diseases involving spinal cordDiseases involving spinal cord

1. Multiple sclerosis1. Multiple sclerosis

2. Spinal cord injuries2. Spinal cord injuries

- suprasacal- suprasacal

- sacral- sacral

Diseases distal to the spinal cordDiseases distal to the spinal cord

1. Disc diseases and spinal stenosis1. Disc diseases and spinal stenosis

2. After pelvic surgery2. After pelvic surgery

3. Herpes3. Herpes

4. Diabetis mellitus4. Diabetis mellitus

URODYNAMICSURODYNAMICS

(Urodynamic studies, urodynamic (Urodynamic studies, urodynamic testing)testing)

1. Uroflowmetry1. Uroflowmetry

2. Cystometrogram2. Cystometrogram

3. Pressure flow studies3. Pressure flow studies

4. Urethral pressure profilometry4. Urethral pressure profilometry

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Urology Lecture