UROLOGY Lecture 2024 PDF

Surgery II MD 420 Coordinator: Dimitrios Ntourakis MD, PhD, FACS UROLOGY STONE DISEASE Etiology –Urinary pH, ionic strength, solute concentration. –The higher the solute concentration of 2 ions the more likely to precipitate. When activity product reaches a specific point termed solubility product (...

Surgery II MD 420 Coordinator: Dimitrios Ntourakis MD, PhD, FACS UROLOGY STONE DISEASE Etiology –Urinary pH, ionic strength, solute concentration. –The higher the solute concentration of 2 ions the more likely to precipitate. When activity product reaches a specific point termed solubility product (Ksp) they became metastable and can initiate crystal growth and heterogeneous nucleation. –When increasing up to the formation product (Kfp) homogenous nucleation can occur. –Concentration product of 2 ions is the product of multiplying their concentration. It is usually higher than solubility products. Why they do not form stones? –Complexation: ions react and complex with others and decrease the free ionic form. Sodium and oxalate complex and the free ionic oxalate is decreased. –Inhibitors: substances in the urine that prohibit crystal formation: magnesium, citrate, pyrophosphate and some trace metals. Matrix component Uric acid 2-10% of stone. Byproduct of purine metabolism. Usually proteins Sodium Calcium Regulates calcium stone formation. Maybe the most common ion found in stones. High dietary intake increases urinary Calcium excretion, decreases urinary pH, decreases urinary citrate (inhibitors). Oxalate Byproduct of the diet. Absorbed by the small intestine is not metabolized and excreted in the urine from the proximal tubule. Phosphate Found in calcium phosphate and magnesium ammonium phosphate stones. Related to the diet. Meat, dairy products and vegetables. Increase calcium stones Citrates Inhibit stone formation Kidney- ureteral stones SYMPTOMS Pain –Renal colic due to the distention of collecting system –Sharp on obstruction, dull in other cases. –Small stones cause big pains. –In flank area but can radiate to scrotum or vulva, testicle and can also be felt at the upper ipsilateral abdominal quadrant. –Urinary frequency, can mimic prostatitis, urethritis. Hematuria –Almost certain microscopic hematuria, often macroscopic Infection –Struvite stones synonymous to infection –Obstruction can cause pyonephrosis (gross pus in an obstructed kidney) and sepsis. Nausea and vomiting Diagnosis KUB films IVU US CT and CT pyelography Treatment Observation. –For stones 40 ml - Ejaculate and erectile dysfunction. - Decrease by 50%. Tadalafil 5 mg Improves symptoms and erectile function Plant-extras -Have anti-inflammatory, anti-androgenic and estrogenic effects. Combination therapy Surgical treatment Transurethral resection of prostate (TURP) Transurethral resection in Saline (TURis) Transurethral Incision (TUIP) Laser Prostatectomy –Green light laser: resection –Holmium laser: enucleation TURis TURis LASER Rezum prostatectomy –< 80 ml prostates –Steam evaporation Open prostatectomy –In large prostates –Transvesical –Through prostate capsule TRANSVESICAL PROSTATECTOMY PROSTATE CANCER Prostate cancer is the most common cancer in elderly males in Europe. It is a major health concern, especially in developed countries with their greater proportion of elderly men in the general population. The incidence is highest in Northern and Western Europe (> 200 per 100,000), while rates in Eastern and Southern Europe have showed a continuous increase. With the expected increases in the life expectancy of men and in the incidence of prostate cancer, the disease’s economic burden in Europe is also expected to increase substantially. It is estimated that the total economic costs of prostate cancer in Europe exceed € 8.43 billion , with a high proportion of the costs of prostate cancer care occurring in the first year after diagnosis. DIAGNOSIS Symptoms: –None –Hematuria, dysuria, retention, incontinence, back pain. Digital rectal examination –Pca in the peripheral zone of the prostate may be detected by DRE when the volume is about 0.2 mL or larger. In about 18% of all patients, PCa is detected by a suspect DRE alone. –A suspect DRE in patients with a PSA level up to 2 ng/mL has a positive predictive value of 5-30%. – An abnormal DRE is an indication for prostate biopsy. Prostate-specific antigen –PSA is a kallikrein-like serine protease produced almost exclusively by the epithelial cells of the prostate, which is organ- but not cancer specific. –May be elevated in the presence of benign prostatic hypertrophy (BPH), prostatitis and other non-malignant conditions. The level of PSA as an independent variable is a better predictor of cancer than suspicious findings on DRE or transrectal ultrasound (TRUS). – Risk of PCa in relation to low PSA values Free/total PSA ratio –2 forms of PSA: bound to proteins and not bound. Free PSA: the not bound form, PSA: bound and unbound. –Ratio: widely used in clinical practice to differentiate BPH from PCa. –The ratio is used to stratify the risk of PCa for men who have total PSA levels of between 4 ng/mL and 10 ng/mL and a negative DRE. –In a prospective multicentre trial, PCa was found on biopsy in 56% of men with f/t PSA < 0.10, but in only 8% of men with f/t PSA > 0.25. Prostate biopsy –Baseline biopsy: guided by ultrasound. Although a transrectal approach is used for most prostate biopsies, some urologists prefer to use a perineal approach. –At least eight cores should be sampled. The British Prostate Testing for Cancer and Treatment Study recommended 10 core biopsies, with > 12 cores being not significantly more conclusive. –Saturation biopsy: The incidence of PCa detected by saturation repeat biopsy (> 20 cores) is between 30% and 43% –Repeat biopsy: rising and/or persistently elevated PSA. suspicious DRE, extensive (multiple biopsy sites) prostatic intraepithelial neoplasia (PIN) The role of imaging Local disease TRUS (transrectal ultrasound) - The classic picture of a hypo-echoic area in the peripheral zone of the prostate will not always be seen. CT , MRI: not accurate in diagnosis Multiparametric MRI: excellent sensitivity for detecting aggressive Gleason > 7 cancers. Distant disease –CT,MRI: –Bone –PET equivalent in nodal disease. scan: for bone metastasis, PSA>10ng/ml scan: for small nodal disease TREATMENT Active surveillance: monitor the patient and postpone the curative treatment at a future point. Is based on repeated digital rectal examination (DRE), PSA and, most importantly, repeat biopsies. Watchful waiting: monitor the patient and offer a palliative treatment at a future time. To avoid unnecessary treatment complication. Definitions of active surveillance and watchful waiting Curative treatment Radical prostatectomy (Prostate, seminal vesicles, lymph nodes) –Open retropubic RP –Perineal RP –Laparoscopic –Robotic RP RP Complications: incontinence, erectile dysfunction Radiotherapy –EBRT (external beam radiotherapy) –Brachytherapy (transperineal placement of radioseeds in the prostate) Complication: intestinal disorders (bleeding, diarrhea, pain), cystitis, erectile dysfunction, incontinence. HORMONAL TREATMENT LHRH (hypothalamus) → FSH,LH (anterior pituitary gland) → TESTOSTERONE (testes)→ DHT Castration levels of testosterone: below 20 ng/dL (1 nmol/L). Orchectomy LHRH agonists: Chronic exposure to LHRH agonists results in the down-regulation of LHRH-receptors, suppressing LH and FSH secretion and therefore testosterone production. Flare up phenomenon: After the first injection, they stimulate pituitary LHRH receptors, inducing a transient rise in LH and FSH leading to the ‘testosterone surge’ or ‘flare-up’ phenomenon, which begins 2-3 days later and lasts for about 1 week. Combination treatment Surgery + radiotherapy Surgery + hormonotherapy Surgery + radiotherapy + hormonotherapy Radiotherapy+ hormonotherapy Clinical Scenario 1 Man presents with an abdomen (?) pain. What you would do? History Where is the pain When it started Which is the type of the pain Other symptoms Clinical examination Abdomen examination Giordano Vital signs Differential diagnosis Localized disease/ systemic Organ (liver, stomach, kidney) Disease (infection, trauma, cancer..) Our patient: Colicky pain (comes and goes) Flank Radiates to the groin What do you suspect What do you expect to find on physical examination Giordano:+ Abdomen: slight tenderness What tests you should do –Blood tests –Urine tests –Imaging Blood test: negative Urine test: Signs of blood Pyouria Imagine test X ray US CT pyelography Treatment Pain killers Instruction on fluid intake Surgical intervention PART TWO URINARY INCONTINENCE The involuntary loss of urine when the intravesical pressure exceeds maximal urethral pressure. Stress incontinence Urge incontinence Mixed incontinence Overflow incontinence Anatomic (fistula) incontinence Stress incontinence Involuntary loss of urine with increased intra-vesical pressure due to increase abdominal pressure in the absence of detrusor contraction. The sphincter itself is intact. Looses efficiency due to hypermobility and loss of support Post traumatic stress incontinence Sphincter is damaged usually following operations (prostatectomies) or injuries. There is not hypermobility but intrinsic sphincter insufficiency. Symptoms Incontinence when there is a sudden increase in abdominal pressure (cough, laugh etc.) There is no need of urination prior to leakage and the patient looses urine without the sensation of urination. Can be few drops of a larger amount of urine. Diagnosis Detailed history regarding previous condition that affect pelvic floor and how the incontinence appears. Clinical examination, US, Cystoscopy mainly to rule out other pathologies. Urodynamic Treatment Duloxetine (reuptake inhibition of serotonin and norepinephrine at the presynaptic neuron in Onuf's nucleus of the sacral spinal cord) Pelvic floor muscle training Electrical stimulation Operations: Retropubic suspension of vesicurethral segment (Marshall-MarchettiKrantz) Slings (TVT- tension free vaginal tape, TOT-transobturator tape) Artificial sphincter Urge incontinence Incontinence due to increased intravesical pressure due to detrusor contractions. Detrusor contractions are involuntary and cannot be controlled. Due to bladder damage or neurological conditions or other conditions (age, diabetes mellitus, spinal cord lesions, infection, stones, in situ bladder cancer). Symptoms The need of urination is sudden and can not be controlled or suppressed. The feeling of urination usually is present during leakage. Sometimes pain or discomfort is present. Diagnosis History Clinical examination, US, cystoscopy Urodynamic Treatment Anticholinergic/antimuscarinic drugs. Botox (Botulinum toxin (BTX) is a neurotoxic protein produced by the bacterium Clostridium botulinum and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromuscular junction and thus causes flaccid paralysis). Cure underlying disease (stone, infection, cancer) Surgery Bladder augmentation Continent urinary diversion Mixed incontinence Stress+urge incontinence at various degrees. Combination of symptoms. Opening of bladder neck and starting of urination in stress incontinence can trigger urge incontinence. Treatment is a combination of the treatment of the two pathologies. Overflow incontinence When the capacity of bladder reaches its maximum and sphincter cannot hold the urine without actual or significant need or feeling of urination. Usually distend and flaccid, not contractile bladder. Usually due to progressive damage of the bladder due to bladder outlet obstruction (prostate, urethra stricture) or neurological causes. Symptoms The need of urination is small or lacking. Sometime can be perceived like urination from elderly patients. Usually small amount of leakage. Treatment Try to decrease every possible outlet resistance (treatment for prostate or urethral strictures). Increase bladder contraction (distigmine bromideparasympathomimetic drug). Clean intermittent catheterization Permanent catheter Sphincterotomy and artificial sphincter placement Anatomic (fistula) Usually post traumatic or iatrogenic. Congenital There is a communication of the bladder with the vagina. Ectopic position of the ureter below the sphincter Symptoms Continuous leakage of urine with the feeling of urination. They might not be normal urinations at all. Urine leakage from abnormal orifices (vagina) Treatment Surgery Close or remove the fistula Reposition of the ureter INFECTIONS/INFLAMATIONS OF THE GENITOURINARY TRACT ACUTE PYELONEPHRITIS Aerobic Gram(–) bacteria (E. coli, Klebsiella, Proteus). –Proteus produce urease (enzyme) that splits urea and produce high alkaline urine which favor the formation of struvite stones (magnesium ammonium phosphate) and apatite stones (calcium phosphate ). Involves both parenchyma and pelvis. One or both kidneys. Usually ascending. Gram(+) bacteria (Staphylococci- Epidermidis/Saprophyticus, Aureus) Streptococci group D. Staphylococci: haematogenous route- abscesses. Symptoms and Signs Usual abrupt onset with fever and shaking chills. Moderate /high fever (38+) Flank pain Symptoms of cystitis (urgency, frequency, dysuria) Nausea, vomiting, diarrhea. Giordano: + Hemogram: Leucocytosis Urinalysis: Heavy pyuria, bacteriuria, mild proteinuria, microscopic or gross hematuria Chronic pyelonephritis Usually refers to chronic renal scaring without the presence of infection Episodes of acute pyeloneprhitis Signs and symptoms Asymptomatic except when episodes of acute infection exist. Blood tests and urine tests can be normal Complications: hypertension, renal stones, uremia, renal impairment Acute cystitis E.coli, Klebsiella, Staphylococci, enterococci. Infection ascends from urethra Hyperemia, edema, infiltration by neutrophils, hemorrhagic surface of urothelieum. Muscle remains intact. Symptoms and Signs Usual abrupt onset with fever and shaking chills. Moderate /high fever (38+) Flank pain Symptoms of cystitis (urgency, frequency, dysuria) Nausea, vomiting, diarrhea. Giordano: + Hemogram: Leucocytosis Urinalysis: Heavy pyuria, bacteriuria, mild Acute bacterial prostatitis Gram(–): (E. coli, klebsiella etc), enterococci. Urethral ascend, reflux in the prostatic gland (detrusor-sphincter dyssynergia), hematogenous, lymphatogenous. Symptoms and Signs Fever with chills, frequency, dysuria, perineal pain, bladder outlet obstruction, possible retention, back pain. DRE: swollen painful prostate, prostate massage contraindicated! Hematuria, urine culture positive. Chronic bacterial prostatitis Chronic prostatitis: bacterial, non-bacterial. Gram-, Gram +(?), Mycoplasmas, chlamydiae, ureaplasma, virus (?) Pathology: non specific, generalized inflammatory reaction. Symptoms and Signs Dysuria, frequency, pain in urination, burning sensation, pain in the glans, edema in the urethral orifice, difficulty in voiding, hematuria, hemospermia, erectile dysfunction, pain in the penis, perineal pain, back pain, pain in the inner thighs, pain in the scrotum. DRE: normal, soft, painful, enlarged. Urine culture: often negative Sperm culture: usually positive Acute epididymitis Sexual transmitted (Chlamydia, Ureaplasma, N. Gonorrhoeae) Non sexually transmitted (E. Coli) possible due to backflow of urine to the vas deferens