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SRMC – Jan’ 2000Urology overview www.medindia.net
Dr. SUNIL SHROFFProf.Urology & Renal Transplantation
Sri Ramachandra Medical College & Research Institute
(Deemed University)Chennai, India
AN OVERVIEW OF UROLOGY
SRMC – Jan’ 2000Urology overview www.medindia.net
UROLOGY – SUB-SPECIALISATION
General Urology
Endo-Urology - Upper Urinary Tract Lower Urinary Tract
Pediatric Urology
Reconstructive Urology / Urodynamics
Andrology - Impotence & Infertility
Female Urology
Renal Transplantation & Access Surgery
Uro-Oncology
SRMC – Jan’ 2000Urology overview www.medindia.net
IMPORTANT UROLOGY TOPICS Calculus Disease of Urinary Tract
Renal Cell Carcinoma & Wilm’s Tumour
Transistional Cell Carcinoma of Bladder
Benign Hyperplasia of Prostate Gland
Carcinoma of Prostate Gland
Testicular Tumours
Undescended Testis
Urethral Stricture
Genito-Urinary Tuberculosis
SRMC – Jan’ 2000Urology overview www.medindia.net
Calculus Disease of Urinary Tract
SRMC – Jan’ 2000Urology overview www.medindia.net
Renal Cell Carcinoma &
Wilm’s Tumour
SRMC – Jan’ 2000Urology overview www.medindia.net
Benign Hyperplasia of Prostate Gland
SRMC – Jan’ 2000Urology overview www.medindia.net
Carcinoma of
Prostate Gland
SRMC – Jan’ 2000Urology overview www.medindia.net
BENIGN TUMOURS OF KIDNEY
ADENOMA
ANGIOMYOLIPOMA ( RENAL
HAMARTOMA)
ONCOCYTOMA
SRMC – Jan’ 2000Urology overview www.medindia.net
MALIGNANT TUMOURS OF KIDNEY
CHILDREN WILM’S TUMOUR
ADULTS
ADENOCARCINOMA OR RCC
TRANSITIONAL CELL CARCINOMA OF THE
RENAL PELVIS ( Lining of renal pelvis same as
bladder)
SQUAMOUS CELL CARCINOMA OF KIDNEY
SECONDARIES OR METASTATIC TUMOURS
SRMC – Jan’ 2000Urology overview www.medindia.net
POINTS WORTH REMEMBERING
70% OF ASYMPTOMATIC MASS OF KIDNEY ARE BENIGN
CYSTS OF NO SIGNIFICANCE
ULTRASOUND CAN DISTINGUISH CYSTS FROM SOLID
LESIONS
ALL BENIGN TUMOURS OF KIDNEY SHOULD BE TREATED AS
MALIGNANT UNLESS OTHERWISE PROOVED
SRMC – Jan’ 2000Urology overview www.medindia.net
ANGIOMYOLIPOMA
BLOOD VESSELS
THREE COMPONENTS SMOOTH MUSCLE
ADIPOCYTES
ASSOCIATED WITH TUBEROUS SCLEROSIS ( Hereditary condition associated with Mental Retardation /
Epilepsy / Sebaceous cysts & Hamartomas )
CAN BE BILATERAL OR MULTICENTRIC
ABNORMAL BLOOD VESSELS CAN BLEED
CAUSING PAIN
SRMC – Jan’ 2000Urology overview www.medindia.net
ANGIOMYOLIPOMA
DIAGNOSIS USG & CT SCAN
( Fat has a typical Hounsfield number on cat scan )
TREATMENT
USUALLY CONSERVATIVE
SURGERY - NEPHRON SPARING SURGERY
SRMC – Jan’ 2000Urology overview www.medindia.net
RENAL CELL CARCINOMA
SYNONYMS
GRAWITZ TUMOUR
HYPERNEPHROMA
ADENOCARCINOMA OF
KIDNEY ( Better term )
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - INCIDENCE
3% OF ADULT MALIGNANCIES (USA)
SEX RATIO M : F - 2 : 1
Commoner in 5th to 7th decade
Von Hippel-Lindau Ds has higher incidence of
RCC
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - ETIOLOGY
Cell of origin Proximal convoluted tubular
cells
( renal adenoma also has same cells of origin)
Higher incidence noted in smokers
Most consistent chromosomal changes observed
Deletion & Translocation of Short arm of
Chromosome 3 (3p).
SRMC – Jan’ 2000Urology overview www.medindia.net
PATHOLOGY (RCC)
General examination
Site Usually - Upper or Lower pole
Surface Smooth & lobulated
Local spread It can penetrate capsule & involve adjoining structures.
RCC Can Infiltrate1.Adrenal
2. Peri-nephric fat3. Adjoining tissues
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - PATHOLOGY
Cut Section :VARIEGATED – SEMICYSTIC & SOLID AREAS - RED OR YELLOW APPEARANCE
Microscopic Examination:
Two type of cells seen -
a). Clear cells with fat & glycogen.
b). Pink Mitochondrial Granules in cytoplasm
( Hence variegated appearance )
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - CLINICAL FEATURES - 1
Painless
1. Haematuria (40%) Profuse
Paroxysmal
2. Pain (40%)
3. Mass (24%)
( All the three if present called classical triad –
Occurs only in 10%. Two of triad in 25% )
4.Varicocele - 1%
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - CLINICAL FEATURES - 2
OTHER FEATURES CAN BE DIVIDED INTO
a). Systemic Effects
Stuffer Syndrome
Hypercalcemia
Erythrocytosis
Hypertension
Enteropathy
b). Non-specific Effects
PUO
Anaemia
Raised ESR
Amyloidosis
Neuro-myopathyStuffer Syndrome – RCC with all symptoms & signs of
alcoholism & Abnormal LFT’s but Normal liver biopsy
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC- DIFFERENTIAL DIAGNOSIS
1. Kidney Hydonephrosis Polycystic kidneys
2. Liver: HepatomaSecondaries
3. Adrenals Neuroblastoma
4. Retro-peritoneum: Mesenteric cystLipoma sarcomaLeiomyosarcoma
SRMC – Jan’ 2000Urology overview www.medindia.net
Staging of RCC
TNM staging & Holland’s staging
Holland’s Staging Stage 1 - Tumour within Capsule
Stage 2 - Tumour involving Perinephric Fat but not
through Gerota’s Fascia
Stage 3 - Tumour involving Regional LN & / or IVC
Stage 4 - Tumour involving adjacent organs or
distant metastasis
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - Treatment
For Stage 1 & 2 Disease
RADICAL NEPHRECTOMY
Best & most Effective T/t for RCC
Excise Kidney en bloc with Gerota’s fascia and Adrenal glands and Lymph Nodes
( Thoraco-abdominal approach may be necessary, if
renal vein involved and tumour reaches Rt. Ventricle. May need to put patient on By-pass machine)
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - Treatment
RCC- Stage 3 or 4 :1. Chemotherapy: RCC Refractory to most drugs
2. Hormonal Therapy: Provera - 15% response (Bloom)
( Medroxyprogesterone acetate given twice a week)
3. Immunotherapy: Interferons - Side effects can be
serious
(1st Lymphokine to receive permission for clinical trials)
4. Palliative nephrectomy : Rarely can cause regression of
distant mets e.g. canon-
ball Sec.
SRMC – Jan’ 2000Urology overview www.medindia.net
RCC - PROGNOSIS
Poor prognosis:
1.RCC involving renal vein
2.Extension through Gerota’s fascia
3. Involvement of regional lymph nodes
4. Mets to distant organs
SRMC-Oct’99
WILM’S TUMOUR
SRMC – Jan’ 2000Urology overview www.medindia.net
WILM’S TUMOUR Synonymus:
Nephroblastoma
Incidence: 13 to 20% of malignant tumours of children under 15 yrs. No difference in incidence in different parts of the world.
Usually unilateral But can be bilateral
Age: Peak at 2 yrs. 75% below 5 yrs. Rare below 6months
Pathology: Colour: Grey white
Cell of origin: Speculative
Embryogenic - “Cell rests” Blastema cell present
Genetic - associated with aniridia/ spina bifida/ GU
abnormalities
SRMC – Jan’ 2000Urology overview www.medindia.net
WILM’S TUMOUR - Pathology
Pale Colour
Cut Section Solid or semicystic
Areas of necrosis
Embryonic Blastema
Mesenchymal Stroma – Cartilage
Microscopic Exam. – or muscle tissue
Epithelial Tubules - most distinctive resembles
glomeruli & Immature tubules
SRMC – Jan’ 2000Urology overview www.medindia.net
WILM’S TUMOUR - CLINICAL FEATURES
1. Mass in abdomen - May grow to a huge mass. Tumour grows within capsule and pushes kidney to one side. Hence shape of tumour not reniform
2. Pyrexia - PUO in 50% of patients.
3. Haematuria - Poor prognosis. Usually due to Encapsulated tumour infiltrating through
capsule.
SRMC – Jan’ 2000Urology overview www.medindia.net
WILM’S TUMOUR - TREATMENT
1. Radical Nephrectomy and post-op radiotherapy.
2. Bilateral Wilm’s - Role of Nephron conserving surgery.
Prognosis: If presentation under 1 yr prognosis good
SRMC – Jan’ 2000Urology overview www.medindia.net
BENIGN PROSTATE HYPERTROPHY (BPH)
BPH is the MOST COMMON benign
tumour in men
Men surviving over 50 years and who
live up to 80 years stand 20 to 30%
chance of undergoing surgery for BPH
SRMC – Jan’ 2000Urology overview www.medindia.net
BPH - PATHOLOGY
McNeal (1990) - divided prostate in Four distinct zones:
1. Anterior Zone
2. Central Zone
3. Peripheral Zone
4. Transition Zone - ( BPH ) this zone coincides with Lateral lobes of prostate
SRMC – Jan’ 2000Urology overview www.medindia.net
BPH - Microscopic Examination
BPH characterised by BPH characterised by NodulesNodules Both Epithelial & Stromal elements involved to varying Both Epithelial & Stromal elements involved to varying
degreedegree
Based on above Five types of Histopathology described:Based on above Five types of Histopathology described:
1. Stromal
2. Fibromuscular
3. Muscular
4. Fibroadenomatous
5. FIBROMYOADENOMATOUS - the most common type.
SRMC – Jan’ 2000Urology overview www.medindia.net
DOG they say is a man’s best friend, DOG they say is a man’s best friend,
certainly this is true when it comes to certainly this is true when it comes to
development of BPH, in mammals - only in development of BPH, in mammals - only in
Dog & man does prostate hyperplasia takes Dog & man does prostate hyperplasia takes
place spontaneously !!place spontaneously !!
But man is not dog’s best friend as all the But man is not dog’s best friend as all the
experiments are done on dog’s prostate !!!experiments are done on dog’s prostate !!!
Prostate and The Story of Dog & His Master
SRMC – Jan’ 2000Urology overview www.medindia.net
BPH - Symptoms
With Progressively obstructive gland constellation of symptoms called - “PROSTATISM” develops.
Irritative Symptoms Obstructive SymptomsFrequency Hesitancy
Urgency Poor stream - Force/Calibre
Nocturia Post-Void Dribbling
Urgency Incontinence Feeling of Incomplete Voiding
Straining to pass urine
Urinary Retention
SRMC – Jan’ 2000Urology overview www.medindia.net
Obstructed muscle
Hyperplasia & Hypertrophy
Deposition of collagen fibres
Lead to a loss of “Bladder Compliance”.
This can also lead to loss of normal control over the Reflex
detrusor response causing “detrusor decompensation” and
“detrusor Instability”
Detrusor Instability can be Confirmed by Urodynamics study - this study measures Detrusor pressure during Filling phase & Voiding Phase of bladder
Detrusor response to Obstruction
SRMC – Jan’ 2000Urology overview www.medindia.net
BPH- AETIOLOGY
Remember AGE & TESTIS
With age, Sensitivity of Prostatic glands to
circulating androgens increases
With age, there is a decrease in androgens
( Testosterone & Dihydrotestosterone) & this
induces the prostate to grow
( ANDROGENS play a major role in development of BPH )
SRMC – Jan’ 2000Urology overview www.medindia.net
BPH- SIGNS 1. Per Rectal examination –
Size of the gland – in mls/ gms
consistency – Firm / Hard
shape - Regular / Irregular
(BPH causes smooth, firm & elastic enlargement of prostate. Obstructive Symptoms No relation to Size of gland )
2. Signs of CRF -Look for signs of anaemia, Evidence of weight loss, Cardiomegaly or Pulmonary oedema
SRMC – Jan’ 2000Urology overview www.medindia.net
DIFFERENTIAL DIAGNOSIS
1. Stricture of Urethra
2. Carcinoma of Prostate
3. Neurogenic Bladder
4. Vesical Calculus
5. Urinary tract Infection
SRMC – Jan’ 2000Urology overview www.medindia.net
BPH -Investigations1. Hb2. Electrolytes / BUN/ Creatinine3. Prostate Specific Antigen / Acid Phosphatase3. Flow Rate : To measure the speed of flow of the urine depicted usually as a graph
4.MSU / CSU- For culture & sensitivity of urine 5. KUB plain x-ray of the abdomen6.US of abdomen – Besides KUB also ask for Post-void residual. Normally there should be nil or minimum residual i.e. less than 50 mls after voiding ( Presence of residual means incomplete voiding
SRMC-Oct’99
Hippocrates & Galen declared that surgical opening of the Bladder was usually fatal & should be avoided!!
SRMC – Jan’ 2000Urology overview www.medindia.net
Open ProstatectomyWrong term
It should be called adenomyomectomy, as whole prostate not removed, only adenoma removed
Trans-vesical (Freyer’s)
Retro-pubic (Millin’s)
Perineal (Young’s)
( For any prostate surgery always warn patient about retro-grade ejaculation and always take consent for the same )
SRMC – Jan’ 2000Urology overview www.medindia.net
Treatment Modalities for BPH
1. Trans-urethral resection of prostate
2. Trans-Urethral Incision of the Prostate
3. Laser Prostatectomy - Nd:YAG laser
4. Microwave Hyperthermia
5. Cryo-surgery of prostate
6. Ultrasound Ablation
7. Balloon Dilatation of the Prostate
8. 8. Drugs: (BPH) –
Alpha- blockers - Prazosin / Terazosin
5-alpha reductase - Finasteride
SRMC – Jan’ 2000Urology overview www.medindia.net
TUR SyndromeAbsorbed Glycine Free Ammonia
(Neurotoxin). Absorbed Glycine Cross the blood-brain barrier & act as inhibitory transmitter
Water can be used but absorption causes hemolysis of RBC’s)
Syndrome characterised by dramatic Reversible Neurological symptoms which are reversible: Mental confusion
Shortness of breath
Bradycardia
Cyanosis
Increase or decrease of BP
Oliiguria
Coma
SRMC – Jan’ 2000Urology overview www.medindia.net
Complications of Surgery
1. Haemorrhage :
2. TUR SYNDROME
3. Incontinence
4. Sexual Dysfunction – Retrograde ejaculation ( 50%) Erectile Impotence (5 to 10% )
5. Urethral Stricture - 1 to 12%
6. Re-operation & Death