What Is Urology

1
What Is Urology?

• A surgical field
• A medical field
• Urinary Tract
• Male Genital Tract

2
A Urologist a friendly, funny, and happy
surgeon"

• Why so happy?
• A discrete field
• True experts
• Rapidly evolving
• Efficacious treatments
• Better surgical lifestyle
• general surgeons are jealous (GH Jordan)

3
Urology Now Subspecialties

• Laparoscopy
• Stones/Endourology
• Oncology
• Incontinence/Voiding
• Reconstructive Surgery
• Transplant
• Sexual Dysfunction
• Infertility
• Pediatric

4
Rotation Goals

• Goal A general overview of urology
• Preceptor based rotation
• Two 1 week preceptorships
• Try to cover all bases
• Obtain schedule from preceptor
• Call preceptors office
  before rotation starts
• Questions or concerns?
• Please communicate
• Let me know if something is
  wrong

5
Weekly Events

• Obtain weekly schedule from preceptor
• Teaching Rounds (with residents)
• Thurs AM (8am-11am) at Alberta Urology Institute
• Grand Rounds
• Friday AM (7am-8am) at Alberta Urology Institute
• Interesting Case Rounds
• Tues AM (7am-8am) at AUI
• If convenient (in office or at RAH that day)
• Alberta Urology Institute
• 400 Hys Centre
• Labcoats please

6
Genitourinary Imaging Case Concepts

• Keith Rourke
• Division of Urology

7
Case 1 Flank Pain

• 50 year old female
• Left flank pain (intermittent)
• Other questions?

-?Trauma -?Hematuria -?Fever -?Voiding
Symptoms -?Smoker -?Calculi history -?UTI history
8
Physical Exam

• T 37.3 PR 108 RR 20 BP 130/88
• Abdomen
• Normal sounds, contour
• Soft, no mass, no organomegaly
• Mild left CVA tenderness

9
Further Testing

• Laboratory
• WBC 10.6, Cr 80
• U/A 50 RBC/hpf
• Plain film (KUB) normal
• ? Radiologic tests

10
Intravenous Pyelogram (IVP)

• Scout film
• Intravenous contrast
• Serial xrays
• Nephrogram phase (1min)
• Pyelogram phase (5 min)
• Delayed views (ureter)
• Post void
• Tomograms

11
IVP Left kidney Case patient
12
Filling Defect Differential Diagnosis

• Stone
• Tumour (TCC)
• Blood clot
• Fungal debris (fungus ball)
• Vascular impression
• Sloughed papilla
• ? Next test

13
Non-contrast CT Abdomen
14
Renal Colic

• Sudden, intense flank, groin or genital pain
• Associated nausea vomiting
• Restlessness, uncomfortable in any position
• gt75 microscopic hematuria
• Similar presentation
• Aortic aneurysm
• Acute bowel obstruction
• Diverticulitis

15
Renal Colic Diagnosis

• KUB
• 80-90 of stones are radio-opaque
• Phleboliths
• IVP
• Demonstrates stone location degree of
  obstruction
• Time consuming contrast risk
• CT (Non-contrast)
• Quick, sensitive
• Concurrent intra-abdominal pathology

16
IVP Ureteral Calculus
17
IVP Complications Contrast reaction

• 5-8 incidence (lt1 severe)
• Mild
• Flushing, nausea, urticaria
• Moderate
• Bronchospasm, angioedema
• Severe
• Hypotension, arrythmia, pulmonary edema
• Treatment
• Diagnosis, IV fluids, antihistamine, epinephrine
• Prevention
• Premedication Benadryl, corticosteroid

18
Non-contrast CT Ureteral Calculus

• Hydronephrosis, perinephric stranding

19
Non-contrast CTUreteral Calculus

• Dilated ureter above stone

20
Ureteral CalculusNon-contrast CT

• Stone visualization location
• All stones are radio-opaque on CT
• Tissue ring sign

21
Renal Colic Management

• IV fluids
• Parenteral analgesia
• Strain urine
• Admission criteria
• Poor analgesia
• Unable to tolerate oral hydration
• Infection obstruction
• Solitary kidney/renal failure
• NOT hematuria, complete obstruction or stone size

22
Renal Colic Treatment

• Spontaneous stone passage depends on
• Location Proximal vs. distal
• Size 80 of stones lt5mm will pass
• Time since onset Most stones pass at 2-3weeks
• Extracorporal shock wave lithotripsy (ESWL)
• Upper ureter or renal stones lt2cm
• Ureteroscopic
• Ureteral stones or ESWL failures
• Percutaneous
• Large gt2cm renal stones

23
Case 2 Gross Hematuria

• 68 year old male
• Gross hematuria

• On History
• Smoker
• No flank pain
• No calculi history
• No trauma

24
Case 2 Examination Lab

• PR 80 RR18 BP 155/80 T 37.2
• Abdomen
• No mass, tenderness or organomegaly
• GU
• Normal penis, testes spermatic cord
• Urine cytology Few atypical cells
• ? Radiologic Investigations

25
Renal Ultrasound (left)

• Normal study
• Note parenchyma, renal sinus

26
Renal Ultrasound (right)

• Low level echogenic focus
• ? Differential diagnosis

27
Renal Ultrasound

• Quick, safe, inexpensive
• Suitable for detecting
• Hydronephrosis
• Renal masses
• Renal cysts (excellent)
• Renal stones (but not ureteric)
• Initial study (upper tract) for hematuria
• ? Next test

28
IVP Evaluation of collecting system
29
CT Abdomen No contrast
30
CT Abdomen After Contrast

• Any further radiologic testing ?

31
Retrograde Pyelogram

• Standard for imaging renal collecting system
• Cystoscopy performed
• Ureteral orifice cannulated
• Contrast injection
• Selective cytology
• Brush biopsy

? Diagnosis
32
Concurrent Bladder Finding
33
Hematuria

• Microscopic hematuria
• gt3 RBC/hpf is significant
• Evaluate over age 40
• Gross hematuria
• Evaluate at any age
• Causes
• Tumour (renal or bladder)
• Stones
• Infection
• Trauma
• BPH
• Medical

34
Evaluation of Hematuria

• Upper tract evaluation
• Ultrasound
• IVP
• CT
• ? MRI (second line)
• Lower tract evaluation
• Cystoscopy is the gold standard
• Other studies Cytology, U/A, RGPyelogram

35
Transitional Cell Carcinoma (Bladder)

• Most common cause of gross hematuria over age 40
• Male Female (31)
• Most common bladder tumour (gt85 tumours)
• Risk factors
• Smoking
• Dyes (aniline, naphthylamine, benzidine)
• Pelvic irradiation
• Cyclophosphamide
• ? Dehydration

36
TCC Bladder (contd)

• Urine cytology is insensitive but specific
• Radiologic investigations have a high false
  negative rate
• Cystoscopic (visual) diagnosis
• Staging (TNM)
• Ta Papillary tumour invading only mucosa
• Tis Carcinoma in situ
• T1 Invading lamina propria
• T2 Muscle invasion
• T3 Fat invasion (extramural)
• T4 Invading adjact organs

37
TCC Bladder (Treatment)

• Dependent on stage
• Ta
• Transurethral resection (TURBT)
• T1
• TUR Intravesical therapy (BCG)
• T2, T3
• Radical cystectomy urinary diversion
• T4
• Chemo, RT Radical cystectomy

38
TCC Bladder Followup

• Prone to recurrence
• Cystoscopic surveillence
• Every 3months x 2years
• Then q6 months x 2 years
• Then annually

39
TCC Upper tract (Renal Pelvis)

• Uncommon, 6 of all renal cancers
• 50 will develop TCC in bladder
• Evaluate concurrently
• 2-4 of TCC bladder patients have upper tract
• Similar RFs to TCC bladder
• Balkan nephropathy
• Treatment
• Radical nephroureterectomy (excise entire ureter)

40
Case 3 Even More Hematuria

• 62 year old male
• Gross hematuria
• Right flank discomfort
• On history
• No trauma
• No urolithiasis
• PMH Hypertension

41
Case 3 Contd

• On Exam
• Abd RUQ pain, No discrete mass, No
  organomegaly
• GU Right varicocele, No hernia
• DRE Benign prostate, Mildly enlarged
• Lab
• Cr 98 , N CBC
• U/A gt50 RBC/HPF
• Flex Cystoscopy Normal

42
IVP Not very helpful

• Possible Mass effect inferiorly (circle)

Obliteration of contour calyx (arrow)
43
Renal Ultrasound

• Mixed echogenic mass (right kidney)

44
Differential Diagnosis Renal Mass

• Renal Cell Carcinoma
• Oncocytoma
• Angiomyolipoma
• Lymphoma
• Upper tract TCC
• Metastatic lesion
• Other Sarcoma, Squamous cell carcinoma

45
CT Abdomen (with contrast)

• Solid renal mass
• Contrast enhancement
• Areas of central necrosis
• Assymmetric margins
• Dilated renal vein
• ? Most likely diagnosis
• ? Further radiologic evalation

46
MRI Case 3

• Heterogenous renal mass (circle)

• Renal vein enlargement (arrow)

47
Case 3 MRI

• Right renal vein/IVC thrombus
• Renal cell carcinoma with extension into renal
  vein (tumour thrombus)

48
Renal Cell Carcinoma Epidemiology

• 3 of all adult malignancies
• 90 of malignant renal tumours
• Malesfemales 21
• Arise from proximal convoluted tubule
• Risk factors
• Smoking (mild)
• von Hippel Lindau (VHL) syndrome
• Bad luck

49
Renal Cell Carcinoma Presentation

• Age 40-60
• 60 are incidentally discovered (ultrasound,
  etc)
• Hematuria
• 15 have classic triad of flank pain, abdominal
  mass, hematuria
• Paraneoplastic syndromes
• Hypercalcemia
• Increased LFTs (Staufer sydrome)
• ACTH
• Hypertension, etc.

50
Renal Cell Carcinoma Diagnosis

• Based on radiographic studies
• Incidental ultrasound
• CT is the method of choice
• MRI
• Assess large tumours/local extension
• Assess for renal vein/caval extension (thrombus)

51
RCC Treatment

• Localized disease
• Nephrectomy (is the only cure)
• Radical vs. Partial (small or bilateral tumours)
• Radiotherapy not beneficial
• Chemotherapy ineffective
• Metastases
• Palliative radiotherapy (bony lesions)
• Immunotherapy (Interferon, IL-2)

52
Other Renal Masses Oncocytoma

• lt3 renal tumours
• Benign lesion
• Indistinguishable from RCC radiographically
• Pathologic diagnosis
• Treatment
• Nephrectomy

53
Renal Mass Angiomyolipoma

• Composed of blood vessels, fat muscle
• Benign but prone to hemorrhage (gt4cm)
• Associated with tuberous sclerosis
• CT is diagnostic
• Fat within tumour

54
Case 4 An incidental finding

• 62 year old female
• Sudden onset of hypertension
• Concurrent panic attacks constipation
• Referred to internist
• BP 160/100
• CT abdomen (Rule/out renal hypertension)

55
CT Abdomen With IV contrast
56
Adrenal Mass Differential Diagnosis

• Adrenal adenoma (lt5cm)
• Adrenocortical carcinoma (gt5cm)
• Pheochromocytoma
• Metastases
• Myelolipoma
• ? Further testing

57
Metabolic Evaluation Adrenal Mass

• Serum electrolytes, creatinine
• 24 hour urine
• Catecholamines metanephrines (all patients)
• Cortisol (if Cushing-oid)
• Aldosterone (if hypertensive, hypokalemic)
• ? Next test

58
MRI T1 coronal image

• Medium signal adrenal mass

59
MRI T2 axial image

• Light bulb appearance diagnostic of
  pheochromocytoma

60
Adrenal Mass

• Incidental finding in 1 of all abdominal xrays
  (ultrasound, CT)
• Must exclude pheochromocytoma (metabolic
  evaluation)
• Adenomas are generally small (lt5cm)
• May be endocrinologically active
• Adrenocortical carcinoma
• Lesions gt5cm considered malignant (adrenalectomy)
• MRI is in an excellent diagnostic modality for
  adrenal masses

61
Case 5 My Sack Hurts

• 22 year old male
• Left scrotal pain x 5 hours
• On history

• Sudden onset
• Nausea
• Bumped it in the shower
• No prior episodes
• No voiding symptoms, no hematuria

62
Case 5 On Examination

• Vitals
• PR 104 RR22 BP 132/82 T 37.9
• Abdomen
• Soft, non-tender, no mass, no megaly
• GU
• Normal circumcised penis, no discharge
• Swollen, markedly tender left testes/epididymis
  (no transillumination)
• Normal right testes
• No hernia

63
Case 5 Lab

• WBC 11.2
• Normal BUN,Cr, Elytes
• U/A 3-5 WBC/HPF
• ? Differential Diagnosis

64
Acute Scrotum Differential Diagnosis

• Torsion (of spermatic cord)
• Epididymitis /- Orchitis
• Torsion of testicular appendage
• ? Tumour
• ? Varicocele
• Hernia
• ? Radiographic investigations

65
Scrotal Ultrasound (with Doppler)Right Testicle

• Normal arterial waveform

66
Scrotal Ultrasound (with Doppler)Left Testicle

• Absent arterial flow

Diagnosis Testicular Torsion
67
Testicular Torsion

• Urologic emergency
• Sudden onset, incidental trauma, prior episodes,
  visceral stimulation (nausea)
• Patient age 12-20 in 65 of cases
• Requires prompt surgical intervention (reduction
  of torsion bilateral fixation)
• 97 testicular salvage if lt6 hours
• 55-85 if 6-12 hours
• lt10 if gt24 hours
• Bell clapper deformity (congenital narrowing of
  cord)

68
Testicular Torsion

• Immediate exploration if suspicious
• Imaging if diagnosis uncertain
• Duplex ultrasound
• 82-100 sensitivity
• Operator dependent
• Heterogenous testicle with absent flow
• Nuclear testicular scan
• Seldom performed
• Time consuming
• Was once the preferred radiographic test

69
Epididymitis

• Most common cause of acute scrotum after
  adolescence
• Pyuria (50), Fever (30)
• Increased flow to epididymis/testes
• Cause
• Age lt40 Chlamydia
• Agegt40 E.Coli
• Treatment
• IM Ceftriaxone/PO Azithromycin
• 10 days fluoroquinolone
• NSAIDs
  

70
Torsion of Testicular Appendage

• Torsion of appendix testes or appendix epididymis
• Blue dot sign (seen on scrotum)
• More focal pain (upper hemiscrotum)
• Often difficult to distinguish from other causes
• Treatment
• Conservative
• Pain relief

71
Other causes Acute Scrotum

• Testicular Tumour
• Usually painless unless acute hemorrhage occurs
• Hernia (incarcerated)
• Arising from above the scrotum
• Varicocele (scrotal varices)
• Retrograde flow into testicular veins
• Infrequent cause of pain unless acute thrombosis
  occurs
• May cause infertility

72
FINISHED
73
Varicocele
74
Oncocytoma Angiogram

• Classic spoke wheel angiographic appearance of
  an oncocytoma
• Not diagnostic