5th y

1. ESSAY PASTYEAR UROLOGY (byMelly©)
TOPIC 1: BLADDER TUMOR
DIAGNOSIS
1) US : Echogenicintravesicalmass
2) Plain& IVU: bladderfillingdefect
3) Pelvic&abdominal CT: confirm& stage bladder
tumors
4) Urine cytology
5) Cystoscopy& biopsy:properstaging,degree of
spread
6) Metastaticworkup: x-raychest& bone scan
TREATMENT
a) Superficial bladdertumors(2006)(2008)
1) Endoscopic:Transurethral resection(TURBT)
2) Immunotherapy:Intravesical chemotherapy
(BCG vaccine) 6 weeklyinstillationsfollowed
by maintainance 3weeklyinstillationevery6
months
 Aim:
i) Reduce tumorrecurrence
ii) Avoidtumorprogression
 Indicationsin multiple,big,T1,recurrent
3) Followup: US, urine cytology,cystoscopy,
biopsy
4) Radical cystectomy (forNMIBC) : highrisk
tumorsresistingRx & rapidlyrecurrent
b) Rx of invasive tumors
1) Radical cystectomy(goldstandard)
2) Radical radiotherapy(lessefficient)
3) Bladdersavingprotocol
i) Respondingtumor:Initialchemotherapy
followedbyradiotherapy
ii) Non-respondingtumors:salvage
cystectomy
TOPIC 2: RENAL TUMORS
CLINICAL PICTURE OF RENAL CELL CARCINOMA
(2010)(2014)
SYMPTOMS
1) Asymptomatic- accidentalloma
2) Triad : pain,mass,hematuria
3) Varicocele
4) Paraneoplasticsyndrome:
- Stauffersyd
- Hypercalcemia
- Hypertension
- Hormonal secretions
5) A renal swellingmaybe feltbythe patient.
6) Non-specificsymptoms:anorexia,nausea,
vomiting,…
7) Metastaticpains.
MANAGEMENTOF RENAL TUMORS ( 2008)(2013)
INVESTIGATIONS
a) LaboratoryFinding:
1) Urine analysis:
 Haematuria:grossor microscopic.
 Proteinuria renal veinthrombosis.
2) Bloodpicture: anaemia
b) Radiological Findings:
1) PlainX-Rayof UT
 Enlargedsofttissue shadowof the kidney.
 Obliteratedpsoasline.
 Calcifications10%

2. 2) IVU:
ii) A space occupyinglesion  distorting
&/or amputatingthe calyces.
iii) In late cases  nocontrast excretion  ?
renal veinthrombosis.
3) Upper abdU/S
4) C.T. Scanning tumor staging
5) Arteriography  vascularityof the tumour
6) MRI
7) Screeningformetastases:
i) X-Raychest
ii) Skeletal survey(osteolytic)
TREATMENT (RCC)
1) Radical nephrectomy locallyresectable
 Indications:large tumor&central position
2) Partial nephrectomy(small tumor&periphery)
2) For inoperable cases:locallyirresectable or
metastatic
i) Radiationtherapy(noresponse).
ii) Hormonal therapy.
iii) Cytotoxicchemotherapy
iv) Immunotherapy
3) NephronsparingSurgery(NSS) withsparing
margin
TOPIC 3: OBSTRUCTIVE UROPATHY
TYPES OF URINARY RETENTION (2007)(2010)
1.ACUTE URINARYRETENTION
Painful inabilitytovoid,withrelief of painfollowing
drainage of the bladderbycatheterization
2.CHRONICURINARY RETENTION
Obstructiondevelopsslowly,bladderisdistended
(stretched) verygraduallyoverweeks/months,pain
isnot a feature
CAUSES OF ACUTE URINARYRETENTION (2)
(2006)(2007)(2008)(2010)
a) Men: (2005)
1) Benignprostaticenlargement(BPE) due to
BPH
2) Carcinomaof the prostate
3) Urethral stricture
4) Prostaticabscess
b) Women
1) Pelvicprolapse (cystocoele,rectocoele,
uterine)
2) Urethral stricture;
3) Urethral diverticulum;
4) Postsurgeryfor ‘stress’incontinence
5) pelvicmasses(e.g.,ovarianmasses)
c) Both Sex
1) Haematurialeadingtoclotretention
2) Drugs
3) Pain
4) Sacral nerve compressionordamage(cauda
equina)
5) Radical pelvicsurgery
6) Pelvicfracture rupturingthe urethra
7) Neurotropicvirusesinvolvingthe sensory
dorsal root gangliaof S2–S4 (herpessimplex
or zoster);
8) Multiple sclerosis
9) Transverse myelitis
10)Diabeticcystopathy
11)Damage to dorsal columnsof spinal cord
causinglossof bladdersensation(tabes
dorsalis,perniciousanaemia)
DIAGNOSISOF ACUTE URINARY RETENTION
(2006)(2008)
a) Historyof difficultyorpassage of stone
b) Clinically
1) Palpation&percussionof abd: full tender
bladder
2) DRE for prostaticenlargement,posturethral
stone
3) Genital exmforphimosis,caruncle
4) Neurological exm:flaccidanus,diminishes
/absentbulbocavernousreflex,perianal
hypoplasia(neurogenichyporeflexbladder)
c) US : showfull bladder
d) PXR: showstone inurethra/ spina bifida/sacral
agenesis(neurogenicbladder)

3. e) IVU : evaluate renal condition(hydronephrosis)/
full bladderinpostvoidingfilm
f) Voidingcystourethrography:Dx posturethral
valve
g) Urethral calibration&urethrography: Dx
stricture
h) Urodynamictesting:suspectedneurogenic
bladder
TREATMENT OF ACUTE URINARY RETENTION
(2004)(2016)(2008)(2009)
a) Initial Management:
1) Urethral catheterisation
2) Suprapubiccatheter( SPC)
b) Late Management:
Treating the underlyingcause
HYDRONEPHROSIS (2012)
DEFINITION
 Descriptive termrefertodilatationof pelvisand
calyces.
 It can occur withor withoutobstruction.
CLINICAL DIAGNOSIS
Symptoms
 Wide range:asymptomatic→ renal colic
 Dependingon:
i) Degree:complete orpartial
ii) Time interval:acute orchronic
iii) Etiology:intrinsicVsextrinsic
iv) Laterality:unilateral orbilateral
Signs
Wide range:no signs
1) Abdominal mass
2) Volume overload
3) Azotemia
MANAGEMENT
MANAGEMENTOF OBSTRUCTIVE ANURIA
(2009)(2013)
ANURIA vs RETENTION OF URINE (2008)
ANURIA URINE RETENTION
Complete cessation of
urine formation
DEFINITION
Inabilityto evacuate
bladder completely
Bad
GENERAL
CONDITION
Good
Supravesicalobstruction
(bilateral/unilateral in
solitary kidney)
MECHANISM
Infravesical
obstruction
1) BPH
2) Urethral stricture
1) No desire to urinate
2) No painor loinpain CP
1) Desire to urinate
2) Severe agonizing
suprapubic pain
Empty bladder
EXAM
Full bladder
(suprapubic buldge)
1) Abnormal kidney
function tests
2) US : hydronephrosis,
emptybladder
3) Catheter :no urine
IX
1) Normal kidney
function tests
2) US : full bladder
3) Catheter :urine
pass
1) Urethral
catheterizationthen
remove obstruction
(Rx of cause)
2) PCNL if stone
Rx
Evacuation of
bladder byurethral
catheter

4. TOPIC 4: TRAUMA
1.RENAL TRAUMA(2012)(2013)
DIAGNOSIS
1) Symptoms:
 Flankpain
 Hematuria
 Abdominal distension,n&v
 Abdominal swelling
 Hypotensionsecondarytobleeding
2) Signs:
 Shock,decrease bp
 Ecchymosisof flank
 Flankmass
 Fracture ribs
INVESTIGATION
1) Lab:
 Urinalysis
 Hematuria
 Serial Hct value
2) Imaging:
 CT abdomen& pelvis
 IVU
 US
 PlainXray chest & abd
MANAGEMENT
 Emergencymeasure:
1) Rx of shock
2) Resuscitation
3) Evaluate associatedinjury
 Active observation(blunttrauma):monitor
bp,pulse rate,repeatedhct& imaging
 Surgical exploration:
Absolute indicationinlife threateninghe &
large expandingpulsatile 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) Historyof trauma
b) Symptoms:
- Gross hematuria(82%)
- Abdominal tenderness(62%)
- Suprapubicbruises,ecchymosis,coolness
- Urinary extravasation(rupture)
c) Clinical examination
1) General : signsof shock
2) Abdominal exm:
 Bruisesinlowerabdominal region
 Abdominal tendernessorrigidity
(peritonitis)
 Signsof pelvicfracture withecchymosis
 Tendernessoverpelvicbones
d) Laboratory investigations
Urine analysis:microscopicor gross hematuria
e) Radiological diagnosis
1) Plainx-rayabdomen&pelvis(pelvic
fracture)
2) CT cystography
3) Ascendingcystogram*
 Showsextravasationof dye fromUB
i) In Intraperitoneal rupture of dye
seenextravastinginwhole abdomen
ii) In extraperitonealrupture,dye seen
onlyaroundUB
TREATMENT (2007)(2008)(2009)(2013)(2014)
1) Emergencymeasures&correctionof shock
2) Intraperitoneal(emergency)
- Immediate exploration
- Drainage & repairof tear
- Catheter(7-10 days)
3) extraperitoneal tears:(conservative)
- bladderdrainage bycatheterfor7 days
- antibiotic
- followupfor10 days (imaging)

5. 3.MANAGEMENTOF TRAUMATIC RUPTURE OF
POST-URETHRA (2005)
DIGNOSIS
1) Historyof trauma
2) Retentionof urine
3) Lowerabdominal pain
4) Bleedingatexternal urinarymeatus
5) Signsof shock
6) Suprapubictendernesswith/outcontusionsin
lowerabdomen&perineum(assbladderinjury)
7) Rectal examrevealsprostaticdisplacementin
mostcases
8) Urethral catheterizationshouldbe avoidedasit
may
i) aggravate urethral trauma
ii) introduce infectionintopelvichematoma
9) Retrograde urethrographyisdiagnostic:shows
extravasationof contrastintoperivesical space
TREATMENT
1) Resuscitation&managementof associated
seriousinjuries
2) Suprapubiccystostomyinall avoidopeningtissue
planestoevacuate periprostatichematoma
 Suprapubicdrainage iskeptfor6 months
combinedantegrade cysto-urethrography
(suprapubiccath)
 The latteris managedeither
i) Endoscopically(visual internal
urethrotomy) or
ii) Surgically( bulboprostaticanastomotic
urethroplasty)
TOPIC 4: PROSTATE
MANAGEMENTOF BPH (2004)(2014)
INVESTIGATIONS
a) Uroflowmetry(simple&noninvasive)
N max flowrate (Q-Max) : > 18 ml/sec
(if <10 ml/sec= obstructionorweakdetrusorms
b) Lab investigations
 Urinalysis
 Serumcreatinine
 SerumPSA
b) Imaging
1) Abdominal ultrasonography:
*size of gland,PVR,associatedstone,
hydronephrosis,
2) KUB: radio-opaque calculi
3) IntravenousUrography:
 secretoryfunctionof the kidney
 basal smoothfillingdefectin the bladder
4) Urethro-cystoscopy:incase of hematuria
TREATMENT OF BPH
I) Non- symptomaticBPH: Reassurance,Followup
II) SymptomaticBPH:
a) Conservative Rx:medical treatment
1) 5- alpha- reductase inhibitors:Doxazosin,
Tamsolucin
2) Alphaadrenergicblockers:Finastride,
Dutastride
b) Surgical treatment:
1) Trans-urethral resectionof the prostate
(TURP)
 Goldstandard 90% of cases
2) Opensurgical prostatectomy
(enucleationadenectomy)
i) Verylarge BPH
ii) Concomitantbladderlesionneedsopen
surgery
iii) Patientlimitation(limitedhipjoint
mobility)
INDICATIONPROSTATECTOMY (2008)
1) RepeatedAUR
2) ChronicUR
3) Severe obstructivesymptoms
4) Failure of medical treatment
5) Haematuria
6) Complications:Rec.UTI, Hydronephrosis,
Bladderstonesordiverticula
COMPLICATIONSPROSTATECTOMY (2008)
1. Compof anesthesia
2. intraop :
a. bleeding
b. TUR syndrome
c. Trauma
3. Immediate postop:
d. Bleeding,primaryreaction
e. Problemwithcatheter
f. Re-retention

6. 4. Delayedpostop:
a. Bleeding
b. InfectionUTI
c. Urine leak,incontinence
d. Urethral stricture
PATHOLOGY OF PROSTATE CANCER (2004)
Histopathology
1) Adenocarcinoma
 More than 95%.
 Arisesfromthe epithelium of prostaticacini or
small peripheral prostaticducts
2) Transitional cell carcinoma
 Lessthan 4%
 ArisesfromProstaticurethra,central prostatic
ducts or directextensionfromTCCof the
urinarybladder
DIAGNOSISOF PROSTATE CANCER (2012)
1) CP
2) Digital Rectal Examination(DRE)
 An abnormal DRE isdefinedby:
i) Asymmetricenlargementof the gland
ii) A prostaticnodule
iii) Firmto hard consistency
 Only50% of pts withabnormal DRE prove to
have prostate cancer
 Normal DRE doesnot exclude cancer
3) Prostaticbiopsy
 Is essential forthe diagnosis
 Transrectal ultrasound – guidedprostatic
(TRUS) biopsy
 Indications:
i) ElevatedPSA
ii) Abnormal DRE
iii) Both
4) Imaginginthe diagnosisof prostate cancer
a) Ultrasonography abdominal ortrans- rectal
i) No specificsonographicpattern:
homogenous,heterogeneous,iso,hypo,
or hyperechoec
ii) Size of the gland
iii) Postvoidresidual
iv) Effecton upperurinarytract
v) Assessment of otherabdominal organs
b) MRI
c) Imagingof Skeletal metastasis
i) Bone scan (highsensitivitybutlow
specificity- highfalse+ve result)
ii) ConventionalSkeletalradiography(low
sensitivitybuthighspecificity)
iii) Bone CT
TOPIC 5: EMERGENCIES
MANAGEMENTOF TESTICULAR TORSION
( 2007)(2014)
a) NEONATALTESTICULARTORSION
CLINICAL PICTURE
 The infantisrestless,reluctanttofeeding.
 Hard, large scrotal mass, -ve transillumination.
TREATMENT
It iscontroversial
1) No treatment the testisisalreadynecrotic.
2) Surgical orchiectomywith contralateral
orchipexy.
b) PUBERTAL TESTICULAR TORSION (Intravaginal
torsion)
CLINICAL PICTURE
 Suddenonsetof acute testicularpainand
swelling.
 Severe tenderness.
 Nauseaandvomiting.
 Transverse lie of the testis.
 Scrotal elevationwill increase pain.
 Secondaryhydrocele maydevelop.

7. TOPIC 6: CONGENITAL
POSTERIOR URETHRAL VALVE (2014)
CLINICAL PRESENTATION
 Bilateral flankmasses(hydronephrosis)
 Distendedbladder
 Poorurinarystream (+/- dribbling)
 Diagnostictest:VCUG
 Therapeuticgoal: preserve renal fx,avoidrenal
failure
 30% at riskfor progressive renal insufficiency
DIAGNOSIS
a) Ultrasound
 Keyhole sign
 Thick-walleddistendedbladder
b) VCUG (diagnostictest)
 See bladderneck
 Suddencutoff betweennarrow&dilated part
 With/outreflux
TREATMENT
1) Stabilize criticallyillbaby
2) Urethral ‘feedingtube’
3) Transurethral ‘fulgration’of valves
4) Vesicotomyif renal functionisimpaired
TOPIC 7: UROLITHIASIS / STONES
ETIOLOGY OF BLADDER STONES (2006)
1) Supersaturation of urine
 Dt excessive excretionof poorlysolublesalts
inurine
 Eg : Ca,oxalate,phosphate,uricacid,cysteine,
xanthine
2) Deficiencyof inhibitorsof crystallization
 Eg : Mg, pyrophosphate &/citrates
3) Stasisalongurinarytract
4) Infection
 Shreadsof pus mayprovide nucleusupon
whichcrystalsmay form
 + infectionbyureasplittingorgas proteus 
alkalinizationof urine  encourage pptof
phosphates
COMPOSITIONOF URINARY STONES (2012)
1) Calciumstones
75% of UT calculi
 Radio-opaque
 Either:
i) Calciumoxalate
ii) Calciumphosphate
2) Uric acid stones
 5-15% of UT calculi
 Radio-lucent
3) Triple phosphate stones‘struvite’=staghorn
 Formedof magnesiumammoniumphosphate
(MAP)
4) Cystine stones
 1% UT calculi
 Faintlyradio-opaque
 Formedinacid urine (ptswithexcessive
excretionof cystine inurine dthereditary
metabolicabnormality)
MANAGEMENTOF UPPER URINARY TRACT CALCULI
A. Diagnosis :CP
1. Pain: colicky,dull aching(stretchcapsule)
2. Hematuria
3. Irritative symptoms:urgency,frequency,
dysuria
4. Symptomsof comp: infection,obstruction
5. Obstructive anuria
B. Emergency treatmentof
1) Renal (ureteric) colic
2) Obstructive (calculus) anuria
C. Treatmentof stones(2004)(2006)(2007)
i) SIZE
- Small
- Large
ii) SITE:
- Ureter:ureteroscopy*,ureterolithostomy

8. - Kidney:PCNL*,pyelolithotomy,
nephrolithotomy,pyelonephrolithotomy,
partialradical nephrectomy
- Bladder:cystolithotripsy*,cystolithotomy
- Urethra: pushto bladder,meatotomy
iii) COMPOSITION
A) INVESTIGATIONSOF UROLITHIASIS
a) Laboratory:
1) Urine analysis
 May showhaematuria.
 Pyuriaand bacteruriaare frequent.
 The type of crystalspresentinthe urine
may predictthe compositionof the stone.
2) Bloodurea& serumcreatinine : estimate of
the total renal function.
b) Imaging:
1) X-rays
 PXRof the abdomen: radio-opaque calculi(80-
90%)
 To differentiate renal&gall bladderstones:
i) A rightlateral viewwhenaradio-opaque
shadow(s) isshowninthe rightrenal area.
ii) A renal calculusoverliesthe vertebral bodies
whereasgallstonesare faranterior.
2) IVU isessential
 A post-voidingfilmisessential toshow
ureterovesical andintramural calculi.
3) Ultrasonography
 Valuable in:
i) Pregnancy
ii) Anuricpatients
iii) Allergictothe contrastmaterial
 It showsthe acousticshadowof the stone,
stasisor hydronephrosisare alsoshown.
4) Noncontrast spiral CT
 Usedin radiolucentstonesorureamicpatients
 To showthe site,size and+/- type of stone
B) EMERGENCY TREATMENT
a) RENAL(URETERIC) COLIC:
1) Antispasmodics(e.gkhelline,buscopan,
papaverine,)+painkillers(e.g.voltaren,
indocid,) IM+ diuretics
2) Opiates(onlythe exceptional case)
b) OBSTRUCTIVE (CALCULUS) ANURIA:
1) Short termconservative trial for12 hourswith
diuretics(lasix6amp or 15% mannitol) +
antispasmodics
2) A plainX-Rayandultrasonographyshowthe
obstructingstone(s) andthe conditionof the
kidneys.
3) Uretericcatheterization orJJ stent inevery
case
4) Urinary diversion PCN above the levelof the
obstructionisrequired
C) TREATMENT OF STONES
i) SMALL STONES lessthan5mm indiameter
usuallypassspontaneouslyaidedbyadequate
hydration:
+ Diuretics,e.g.thiazidesone tabletdaily
+ Antispasmodicse.g.khellineproducts,hyocine
(buscopan) orpapaverine(no-spa).
ii) LARGER RENAL & URETERIC STONES :
1) Extracorporeal shockwave lithotripsy
(ESWL)
 suitable forstones <2 cm in diameter
 not assc withdistal obstruction/active
infection
2) Percutaneousnephrolithotomy
 done underfluoroscopic(X-Ray) control
 suitable formostrenal calculi
iii) SURGERY : the role of surgery isdeclining
I) Rx of upperurinarycalculi
a) FOR RENAL STONES
The kidneyisexposedextraperitoneallybya
supracostal incisionwiththe patientlyinginlateral
position.
1) Pyelolithotomy
 extractionof stone throughanincisioninrenal
pelvis
 the operationof choice

9. 2) Nephrolithotomy
 extractionof stone thran incisioninrenal
parenchyma
 suitable forsome calyceal stones which
cannot be extractedviathe renal pelvis
3) Extendedpyelolithotomyorpyelo-
nephrolithotomy isindicatedinbranched
(staghorn) stones.
4) Partial Nephrectomy,
 excisionof the lowerthirdof the kidney
 indicatedincase of stone inthe lowercalyx
whose drainage isdefective
5) Nephrectomy
 shouldbe avoidedeveninmx of staghorn
stones
 it isonlydone fora functionlessdestroyed
kidney,oras a life savingmeasure because of
intraoperative bleedingduringrenal stone
surgery
b) URETERAL STONES
 Ureterolithotomy isindicatedfor
1) large stones
2) stoneswithdistal stricture
3) afterfailure of endourologicmanipulations.
c) LOWER THIRD OF THE URETER STONES suitable
for ureteroscopicmanipulationsincluding:
Disintegrationof largerstonesbyUSor
electrohydraulicwavesorbythe pneumatic
lithoclastorby Laserbeam.
d) IMPACTED STONES IN THE INTRAMURAL URETER
can be extractedcystoscopicallyaftertransurethral
incisionof the submucosal ureter(ureteral
meatotomy).
II) Rx of lowerurinarycalculi
a) BLADDER STONES
Stone : cystolithotripsy
Stones: cystolithotomy
1) Single,mediumsizedstones(1-2cmin
diameter)
 Crushedbylithotrite (litholapaxy)
2) Large calculi
 Manage by extraperitoneallythrough
suprapubicmidlineincision(litholatomy)
b) URETHRAL CALCULI
1) Posteriorurethral calculi are cautiously
pushedbackby a urethral soundor bya
urethroscope tothe bladdertobe treatedas
bladdercalculi.
2) Impactedstonesatthe fossanaviculariscan
be extractedbydoingmeatotomyof the
external urinarymeatus.
3) Bulbarurethral stonescan be extracted
throughthe perineum(bulbar
urethrolithotomy).
4) Stonesinthe penile urethraare pushedback
to the bulbarurethraand treatedas such
TREATMENT
a) Manual detorsion (done from medial to lateral)
Notrecommendedasitisnot a final solution,
torsion:
i) may recur
ii) may be incomplete sothe painisrelieved
but the testisisstill ischemic
b) Surgical exploration
1) Affectedtestis
 if viable detorsionandorchiopexy
 if not viable doorchiectomy.
2) Contralateral testisorchiopexy.