urology overview srmc – jan 2000 dr. sunil shroff prof.urology & renal transplantation sri...

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


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


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


Calculus Disease of Urinary Tract


Renal Cell Carcinoma &

Wilm’s Tumour


Benign Hyperplasia of Prostate Gland


Carcinoma of

Prostate Gland


BENIGN TUMOURS OF KIDNEY

ADENOMA

ANGIOMYOLIPOMA ( RENAL

HAMARTOMA)

ONCOCYTOMA


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


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


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


ANGIOMYOLIPOMA

DIAGNOSIS USG & CT SCAN

( Fat has a typical Hounsfield number on cat scan )

TREATMENT

USUALLY CONSERVATIVE

SURGERY - NEPHRON SPARING SURGERY


RENAL CELL CARCINOMA

SYNONYMS

GRAWITZ TUMOUR

HYPERNEPHROMA

ADENOCARCINOMA OF

KIDNEY ( Better term )


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


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).


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


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 )


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%


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


RCC- DIFFERENTIAL DIAGNOSIS

1. Kidney Hydonephrosis Polycystic kidneys

2. Liver: HepatomaSecondaries

3. Adrenals Neuroblastoma

4. Retro-peritoneum: Mesenteric cystLipoma sarcomaLeiomyosarcoma


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


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)


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.


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


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


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


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.


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


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


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


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.


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


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


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


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 )


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


DIFFERENTIAL DIAGNOSIS

1. Stricture of Urethra

2. Carcinoma of Prostate

3. Neurogenic Bladder

4. Vesical Calculus

5. Urinary tract Infection


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!!


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 )


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


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


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

urology overview srmc – jan 2000 dr. sunil shroff prof.urology & renal transplantation sri...

Documents

urology overview

overview of urology

pain slide

prooved slide

higher incidence of

variegated appearance

rcc incidence

rcc treatment