Urosurgery

·         Hematuria is the most ominous single sign or symptom of urinary system disease.

·         Stress urinary incontinence is seen principally in older females and is produced by pelvic floor relaxation with shortening of urethral length.

·         Blunt renal trauma:

Only those who have gross hematuria need undergo contrast studies.

Microscopic hematuria is no longer an indication for contrast evaluation.

Patients who have blunt renal trauma need to undergo exploration only if they are hemodynamically unstable.

Conservative management in the absence of hemodynamic instability is the current trend.

All penetrating injuries should undergo exploration.

·         Epididymitis can occur in prepubescent males, but it is a rare phenomenon and usually occurs only in patients with chronic UTI, obstructed urethra, or very high voiding pressure. The diagnosis of epididymitis in the prepubertal male should be reviewed with suspicion because one of the more common causes of the clinical situation that presents as epididymitis is torsion of the testicle. If there is any concern about the validity of the diagnosis, the patient should undergo scrotal exploration. Epididymitis will not be compromised by surgical exploration, but delay in surgical exploration leads to loss of the testicle if the problem is torsion.

·         Acute suppurative prostatitis should be treated with vigorous antibiotic therapy with broad-spectrum agents initiated immediately and changed in response to results of culture and sensitivity studies. Urethral instrumentation and repeated prostate examination should not be done, if at all possible, since sepsis is not unusual after either diagnostic examination or urethral catheterization. If the patient does need to have the bladder decompressed, it is beneficial to use a suprapubic catheter rather than a urethral catheter.

·         Renal masses such as benign cysts or renal cell carcinomas will both appear as “tumor deformities”, distorting the renal outline or the collecting system. Renal cysts are far more common than renal cell carcinoma and the diagnosis can be confirmed by renal ultrasound.

·         RENAL CELL CARCINOMA

1.       The classic triad is hematuria, flank pain, and an abdominal mass; however, this traid is found in only 10% of cases.

2.       Surgery is the optimal treatment for localized renal cell carcinoma.

3.       Stauffer's syndrome is diagnosed with elevated liver function tests in the presence of renal cell carcinoma that normalize after nephrectomy and tumor removal; it is thought to be a type of paraneoplastic syndrome.

·         PROSTATE CANCER

1. Prostate cancer is the most common malignancy diagnosed in men.
2. The best screening method is a combination of digital rectal exam and serum prostate-specific antigen.
3. Clinically localized prostate cancer is treated with surgery, radiation, cryotherapy, or watchful waiting.
4. Free PSA is the percentage of PSA that is not bound to a serum protein carrier. The ratio of free to total PSA is helpful in determining when to do a prostate biopsy. "Free" is good because a higher ratio of free to total PSA is less likely to represent a prostate cancer.
5. Gleason's sum: It's a score that the pathologist gives prostate cancer to estimate its aggressiveness. The two predominant patterns of cancer are scored 1 to 5, and the sum is, therefore, between 2 and 10. Tumors can be well differentiated (2, 3, 4), moderately differentiated (5, 6, 7), or poorly differentiated (8, 9, 10).

·         American Urologic Association (AUA) symptom index score for BPH. This score is based on a patient’s 0–5 response to 7 questions (0 = not at all; 1 = less than one-fifth of the time; 2 = less than one-half of the time; 3 = one-half of the time; 4 = more than one-half of the time; 5 = almost always): Over the last month, how often have you:

1. Had a sensation of not emptying your bladder after urinating?
2. Had to urinate again less than 2 h after you finished urinating?
3. Stopped and started again several times when you urinated?
4. Found it difficult to postpone urination?
5. Had a weak urinary stream?
6. Had to push or strain to begin urination?
7. Had nocturia?

A score of 0–7 is mild BPH, 8–19 is moderate BPH, and 20–35 is severe BPH.

·         Urodynamic studies assess the functional aspects of the storage and emptying ability of the lower urinary tract (LUT). The principles of urodynamic studies originated from hydrodynamics. The components of urodynamic studies are cystometrogram, leak point pressures, urethral profile pressures, pressure-flow studies, uroflowmetry, and electromyography. These studies have evolved into videourodynamics with the addition of fluoroscopy (i.e., video).

·         Uroflowmetry is the measurement of voided urine (in milliliters) per unit of time (in seconds). The important elements of the test are voided volume (which should be > 150 mL), maximum flow rate (Qmax), and the curve of the flow (which should be bell shaped). The normal Qmax is > 20 mL/sec in men and > 25 mL/sec in women.

·         Autonomic dysreflexia results from systematic outpouring of sympathetic discharge, as in patients with spinal cord lesions at or above the T6 level. This dysreflexia is triggered by distention of the bladder or other stimulus of the bowel or LUT. It is manifested by hypertension, bradycardia, hot flush, sweating, and headache. Initial treatment consists of removal of the stimulus, such as emptying the bladder and placing the patient in a sitting position. Nifedipine or nitroprusside may be used as either prophylaxis or treatment of severe episodes. This condition may lead to significant cerebrovascular complication if untreated.

·         Diabetic cystopathy is manifested primarily as atonic bladder with difficulty in emptying caused by impaired contractility of the bladder or detrusor muscle.

·         Urgency (83%), urge incontinence (75%), detrusor hyperreflexia (62%), and detrusor sphincter dyssynergia (25%) are among the most common LUT symptoms in patients with MS. Variation in symptoms depends on the site of involvement by MS. Involvement of pontine pathways (tegmentum) is associated with a much higher rate of urinary symptoms.

·         Meyer-Weigert law:

This law refers to the position of the ureteral orifices in patients with complete ureteral duplication. Occasionally, two ureteral buds develop independently from the mesonephric duct. As the ureteral buds are absorbed into the developing bladder, the bud located in a lower position along the duct (draining the lower pole of the kidney) is carried to a more cranial and lateral position. The ureteral bud located in a higher position along the duct (draining the upper pole of the kidney) is carried to a more caudal and medial position within the bladder. Lower pole ureters are more likely to reflux because of their lateral position within the bladder; however, upper pole ureters are more frequently obstructed and are more often associated with a ureterocele.

·         Most common solid renal mass:

In infancy, it is congential mesoblastic nephroma. This is a benign tumor of the kidney that can be managed with surgical excision alone.

In childhood, it is a Wilms' tumor. Wilms' tumor is associated with Beckwith-Wiedemann syndrome, isolated hemihypertrophy, and congenital aniridia. The most important prognostic factors are tumor stage and histology. Treatment is multimodal, consisting of surgery, chemotherapy, and radiation.

·         VARIUS SHUNTS FOR PRIAPISM

A transglanular to corpus cavernosal scalpel or needle-core biopsy (Ebbehoj or Winter technique) is the first reasonable approach for refractory cases (see image below). A unilateral shunt is often effective. Bilateral shunts are used only if necessary (usually apparent after 10 min).

Quackel shunts are cavernosal-spongiosum shunts (unilateral or bilateral) and are performed via a perineal approach. Such shunts are rarely effective if a more distal shunt has already failed (eg, El-Ghorab procedure) because thrombosis of the corpora is usually already present

A Grayhack shunt is a cavernosal-saphenous vein shunt (rarely necessary or indicated

Cavernoso-dorsal vein shunt (Barry): In a Barry shunt, a 4 cm skin incision is made at the base of the penis. The superficial or deep dorsal vein is identified and mobilized. It is ligated distally and divided. The proximal limb is spatulated on its ventral surface and anastomosed to the corpus cavernosum in a tension-free manner (Figure 5). In theory, this shunt should be very effective because the dorsal penile veins are not involved in priapism and it bypasses any distal penile edema or thrombosis. However, in practice, perhaps due to the size of the vein, it has not been as successful as expected.