Genitourinary System

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Genitourinary System

• Rummana Aslam, MD
• 09/2008

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UROLITHIASIS

• Most urinary stones are renal (nephrolithiasis)
• Peak incidence 45-75 years
• 25 fold higher incidence with family history
• Recurrence is significant 50 patients have
  recurrence in 5 to 10 year and 75 in 20 years
• Men 3 fold more inidence than women

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• Composition
• Most have calcium and are calcium oxalate
• 20 are uric acid, struvite or carbonate apatite,
  cystine, and other rare precipitates
• Pathophysiology
• Multifactorial
• Foreign body or crystal nucleus, growth of salt
  crystals and supersaturated urine, stasis as in
  stricture, sites of injury

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• Diagnosis
• Intermittent obstruction
• Pain (usually intermittent, anywhere from flank
  to groin) and hematuria
• Fever usually absent
• Radiographic findings or stone passage
• Plain imaging
• Sonography
• IV urogram
• Spiral CT

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• Management
• Depends on size, location, degree of obstruction
  and complicating factors
• Conservative management
• Immediate intervention in
• Pyelonephritis
• Unremitting pain
• Deteriorating renal function
• High-grade obstruction

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• Treatment options
• Extracorporeal shockwave lithotripsy
• Ureterorenoscopy
• Percutaneous nephrolithotomy
• Open surgery or laparoscopy

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UROTHELIAL CARCINOMA

• Transitional cell carcinoma 90
• Squamous cell carcinoma (5)
• Adenocarcinoma (2)
• Lymphoma (lt1)
• Sarcoma (lt1)
• Men have 3 times more often than women
• Whites twice as often as African Americans
• Single most important factor is tobacco exposure
• (other factors associated are aniline dyes,
  nitrosomine, cyclophosphamide, shistosomiasis,
  chronic irritation, radiation exposure)

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• Diagnosis
• Painless hematuria
• No significant voiding issues unless disease is
  advanced
• Urinalysis screening for culture/cytology
• Radiographic evaluation
• Cystoscopy
• Fluorescence in situ hybridization (FISH) and
  dipstick such as NMP22 (more useful in patients
  with previously treated cancer)
• Staging
• Tissue diagnosis CT abdomen, pelvis

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• Treatment
• Endoscopic resection for superficial tumors
• Adjuvant intravesical chemotherapy
• Radical cystoprostatectomy in men and anterior
  exenteration in women for muscle invasive
  transitional cell carcinoma
• Chemotherapy for metastaic bladder cancer
  (largely incurable) with cisplastin based regimens

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Question 1

• During CT for blunt abdominal trauma, a 45 year
  old woman is found to have a 1.5 cm vascular mass
  in the right kidney. Follow up MRI suggests RCC.
  The next step in management should be
• A Biopsy of the lesion
• B Total nephrectomy
• C Partial nephrectomy
• D Total nephroureterectomy
• E Total nephroureterectomy with aortic
  lymphadenectomy

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RENAL CARCINOMA

• Most common type of renal cell cancer is clear
  cell cancer most commonly referred to as RCC
  (renal cell carcinoma)
• Thought to be derived from PCT
• Have significant vascularity and enhance with IV
  contrast
• Fuhrmans grading system
• 1 is well differentiated 4 is highly
  undifferentiated (worse prognosis)
• Little is known about enviromental risk factors

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• Proposed risk factors
• ESRD, asbestos, high fat diet, obesity, HTN,
  tobacco exposure
• Genetic risk factors are VHL disease, PCKD
• Diagnosis
• Incidently discovered
• CT best modality for assessing clinical stage
  (tumor size, location and extension, adrenal
  involvement)

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• Paraneoplastic syndromes (hypercalcemia,
  erythrocytosis, anemia, amyloidosis, elevated sed
  rate, LFTs, alk phos, ferritin) are common and
  resolve spontaneously after resection of primary
  mass
• RCC has a predilection for invading into the
  renal vein and IVC ( right sided varicocele
  highly suspicious for cancer)
• Staging
• T0 noevidence of primary tumor
• T1 lt 7 cms limited to kidney T2 gt7cms limited to
  kidney
• T3a,b,c locally extensive
• T4 invades beyond Gerotas fascia

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• Weight loss occurs in 3rd of patients
• Treatment
• Surgery is treatment of choice
• Radical nephrectomy involves removal of kidney,
  adrenal gland, proximal ureter en bloc with
  Gerotas fascia
• Partial nephrectomies now advocated for small
  peripheral renal mass
• Patients with tumors smaller than 4 cm, 5 year
  cancer specific survival is 95 or higher
• Satisfactory margin appears to be at least 3 mm

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• Minimally invasive methods that are also used are
  cryosurgery, percutaneous applied radiofrequency
  or cryoablation
• Hematogenous metastasis in advanced RCC (because
  of access of tumors to venous system) occurs to a
  wide number of sites
• Patients with solitary metastasis are still
  candidates for surgical resection
• Better prognosis with delayed solitary
  metastasis- surgical resection associated with
  30 5 year survival
• Spontaneous regression in 1-2. Chemotherapy
  largely ineffective

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Question 1

• During CT for blunt abdominal trauma, a 45 year
  old woman is found to have a 1.5 cm vascular mass
  in the right kidney. Follow up MRI suggests RCC.
  The next step in management should be
• A Biopsy of the lesion
• B Total nephrectomy
• C Partial nephrectomy
• D Total nephroureterectomy
• E Total nephroureterectomy with aortic
  lymphadenectomy

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Question 2

• Which of the following statements about seminoma
  are true
• A It is the most common cancer in American
  men
• B It often secretes alphafetoprotein
• C Cisplastin based chemotherapy is often used
• D It is radiosensitive
• E Survival rates lt 10 are expected for
  patients with advanced disease

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TESTIS CANCER

• Most common cancer in men between ages of 15 and
  34 years
• Nonetheless is a rare tumor accounting for only
  approx. 1 of all cancers in American men
• Risk factors are
• Age
• Pediatric nonseminomatous tumor (e.g yolk sac
  tumor)
• Young adults Seminoma gt nonseminomatous
• Geriatric spermatocytic seminoma, lymphoma
• Whites are at higher risk
• Cryporchidism

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• Family history
• HIV/AIDS (lymphoma)
• Foremost among the risk factors is a history of
  cryptorchidism although only 75 are in the
  testis that failed to descend
• Supportive cell tumors e.g Sertoli or Leydig cell
  tumors are less common and can present with signs
  of hormonal secretion
• Germ cell tumors are categorized as seminomas
  (most common) and nonseminomatous (endodermal
  sinus or yolk sac tumors and choriocarcinoma)

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• Yolk sac tumor secretes AFP and choriocarcinoma
  secretes beta HCG
• Pure seminoma does not secrete AFP but may
  secrete beta HCG in 10 of cases
• Diagnosis
• Most cases by self examination
• Most common finding is abnormally enlarged testis
  or firm nodule

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• Metastatic testis cancer is treatable
• Five year survival rates are greater than 75 for
  advanced disease and greater than 90 for lower
  stage disease
• First step in diagnosis is scrotal
  ultrasonography

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• Treatment
• If tumor suspected than surgical exploration with
  orchiectomy through an inguinal incision for
  definitive diagnosis and initial treatment
• Staging is then accomplished via CT of chest,
  abdomen, pelvis
• Stage 1- confined to testis
• Stage 2 spread to regional nodes

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• Stage 3 spread beyond retroperitoneal nodes
• Stage 4 extralymphatic metastasis
• Seminomas are highly radiosensitive
• Stage 1 and 2 treated with adjuvant radiation
  therapy
• Stage 3 and 4 require cisplastin- based adjuvant
  chemotherapy
• Nonseminomatous tumors are less radiosensitive

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• Nonseminomatous tumors require retroperitoneal LN
  dissection (RPLND), chemotherapy or both
• Stage 1 surveillence, limited chemotherapy or
  RPLND
• Stage 2 (lt 5cms) RPLND followed by chemotherapy
• Bulky stage 2 and 3 treated with chemotherapy and
  then RPLND if tumor markers have normalized and
  residual retropertoneal mass

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Question 2

• Which of the following statements about seminoma
  are true
• A It is the most common cancer in American
  men
• B It often secretes alphafetoprotein
• C Cisplastin based chemotherapy is often used
• D It is radiosensitive
• E Survival rates lt 10 are expected for
  patients with advanced disease

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Question 3

• Affects fertility
• A varicocele
• B Spermatocele
• C Both
• D Neither

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Question 4

• Predominantly left sided
• A varicocele
• B Spermatocele
• C Both
• D Neither

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Question 5

• Require(s) surgical correction
• A varicocele
• B Spermatocele
• C Both
• D Neither

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Disorders of the scrotum

• Hydrocele
• Most common benign lesion accumulation of serous
  fluid secreted by the tunica vaginalis secondary
  to tumor, trauma, inflammation, idiopathic
• Epididymitis
• Mass effect and pain, inflammation due to
  bacterial or chemical insult to vas deferens
• Neoplasia, cystic lesions, testicular torsion,
  ruptured testicle, scrotal abscess

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• Two most common benign nonacute scrotal
  pathologies in adults
• Varicocele dilation of pampiniform plexus
  invariably a left sided process may effect
  fertility
• Spermatocele randomly found, no predilection for
  one side or the other, no effect on fertility
• Neither varicocele or spermatocele require
  surgical correction

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• Diagnosis
• Focused history
• Trauma, UTI symptoms, presence of pain
• Most important is physical exam
• Scrotal transillumination or US (cystic mass
  rarely neoplasia solid suggests neoplasia)
• Treatment
• Epididymitis supportive, analgesics,
  antiinflammatory, antibiotics
• Abscess surgical drainage and evaluation of
  cause (e.g urethral stricture, trauma with
  extravasation of urine)
• Torsion or rupture immediate surgical
  exploration, orchiopexy, orchiectomy depending on
  testicular viability

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Question 3

• Affects fertility
• A varicocele
• B Spermatocele
• C Both
• D Neither

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Question 4

• Predominantly left sided
• A varicocele
• B Spermatocele
• C Both
• D Neither

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Question 5

• Require(s) surgical correction
• A varicocele
• B Spermatocele
• C Both
• D Neither

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Question 6

• Iatrogenic injury of the left ureter with
  electrocautery at the pelvic brim is best managed
  with
• Primary repair over stent
• Ureteroneocystostomy
• Debridement and primary repair over a stent
• Psoas hitch
• Anastomosis to the uninjured right ureter

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Renal Vascular Injury

• Grade 1 contusion hematuria, urologic studies
  normal, subcapsular nonexpanding
• Grade 2 hematomanonexpanding, confined to
  retroperitoneum, lt 1 cm parencymal depth, no
  urinary extrav
• Grade 3 laceration gt 1 cm parenchymal depth, no
  urinary extrav
• Grade 4 laceration extending through cortex,
  medulla, collecting system
• Grade 5 laceration completely shattered kidney
• vascular avulsion of hilum with devascularized
  kidney

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• The major indication for nephrectomy in a patient
  with a major vascular renal injury is persistant
  shock despite ongoing fluid resuscitation or
  grade 5 injury in a normotensive patient
• Grade 4 and 5 injuries Patients with blunt
  injury more likely to have a poor outcome
• Hemodynamically stable patient with grade 4
  repair for both blunt and penetrating

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Question 8

• A 62 y/o woman sustained head, chest and
  abdominal injuries as an unrestrained passenger
  in a high speed MVC. She is hypotensive and FAST
  is abnormal. At laparotomy, a blunt hepatic
  injury of the right lobe is packed because of
  active bleeding. Bleeding continues to arise from
  retroperitoneum, localized to the right hilum. A
  left kidney is palpable. The patient is
  intermitently hypotensive despite ongoing blood
  and crystalloid replacement
• The most appropriate management of the renal
  injury would be

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• Right nephrectomy
• Primary vascular repair
• Retroperitoneal packing renal artery
  embolization
• Damage control laparotomy
• Vascular repair with autologous vein bypass graft