35 Urologic Surgery - Bài viết - Bệnh Học
Đọc và ngẫm: "Lại như xét bệnh còn lơ mơ, sức học còn non đã cho thuốc chữa bệnh, đó là tội dốt nát. [Trích 8 tội cần tránh - Lê Hữu Trác] "
Chú ý: Các nội dung sai QUY ĐỊNHLuật chính tả sẽ bị XÓA
Nếu bạn đang gởi bài, hãy đọc qua bài này!

QuocBaoNet

35 Urologic Surgery

Cho điểm
Urologic Surgery
Tyler L. Christensen
Arnold D. Bullock
Evaluation of Hematuria
I. Hematuria
Hematuria is the hallmark of disease in the genitourinary tract and warrants a thorough investigation. Pain associated with hematuria may suggest a benign etiology such as cystitis or urinary calculi. However, painless hematuria should be regarded as secondary to a tumor until proven otherwise.
  • All of the following warrant a hematuria workup:

    • Any episode of gross hematuria.
    • At least three red blood cells (RBCs) per high-power field on two of three urine specimens.

  • Evaluation of hematuria
    • Freshly voided urine is evaluated with a dipstick and microscopic analysis for the following:
      • Specific gravity is noted because RBC rupture occurs in hypotonic urine (specific gravity <1.008).
      • Urinary pH can aid in the diagnosis of disease.
      • Microscopic analysis evaluates RBC morphology, casts, crystals, white blood cell (WBC) count, and bacteria.
      • The presence and character of clots can be revealing; upper tract bleeding may cause vermiform (wormlike) clots, whereas bladder clots may be amorphous.

    • Complete blood cell (CBC) count and coagulation parameters should be studied with gross hematuria. Serum creatinine is essential before performing a contrast study of upper tracts.
    • Radiologic evaluation of the upper urinary tract is mandatory. Computed tomography (CT) urogram is the preferred imaging modality because it provides greater detail of the renal parenchyma and collecting system in comparison to the older routine of an intravenous pyelogram (IVP) and renal ultrasound. In addition, there is the obvious benefit of viewing the remainder of the abdomen.
    • The lower urinary tract is visualized with cystoscopy.
    • Urine is sent for culture and cytology.
    • If the etiology of the hematuria is not revealed with the foregoing, the patient should have a repeat urinalysis (UA), urine cytology, and a blood pressure measurement at 6, 12, 24, and 36 months (Urology 2001;57:604).

  • Treatment. Gross hematuria requires urgent evaluation.
    • Patients passing blood clots may require irrigation and initiation of continuous bladder irrigation with normal saline via a three-way Foley catheter (22 to 24 French). Prostatic bleeding may be controlled with gentle catheter traction.


Bladder irrigation with 1% alum or 1% silver nitrate can alleviate persistent bleeding. It is imperative that the bladder be free of clots before initiating alum or silver nitrate irrigation. Silver nitrate and alum are astringents that act by protein precipitation over the bleeding surfaces. Initiation of intravenous ε-aminocaproic acid [Amicar; 5 g in 250 mL of dextrose 5% in water (D5W) infused over 1 hour, then 1-g/hour continuous infusion] can also be used to help control bleeding. ε-Aminocaproic acid is an inhibitor of fibrinolysis and can be associated with thromboembolic complications. It should be used judiciously and should not be used in any patient suspected of disseminated intravascular coagulopathy. It may also be given orally or administered intravesically.

    • Persistent bleeding on continuous bladder irrigation or significant gross hematuria in the unstable patient requires immediate cystoscopic evaluation to localize and control bleeding.


Diseases of the kidney
I. Evaluation of Renal Masses

  • Increased use of abdominal CT scanning and ultrasonography has resulted in detection of more asymptomatic renal masses. These masses must be characterized as benign or malignant.
  • The vast majority of masses are benign cysts (Radiology 1991;179:307).
  • Renal cysts occur in one half of persons older than 50 years. Other benign lesions include infarction, abscess, hemangioma, angiomyolipoma, and adenoma. Most solid renal masses (85% to 90%) are renal cell carcinomas (RCCa). Up to 33% of these malignancies are diagnosed incidentally by imaging obtained for other reasons (Abdom Imaging 2002;27:629). Over the last 20 years, the incidence of RCCa has been increasing. Improved imaging and early diagnosis have dramatically increased the number of patients who present with curable disease. Other malignant lesions that present as renal masses include transitional cell carcinoma, oncocytoma (benign in the vast majority of cases), sarcoma, lymphoma, leukemia, and metastatic tumor (lung, breast, gastrointestinal, prostate, pancreatic tumors, and melanoma).
  • Presentation. The historical triad of flank pain, hematuria, and flank mass occurs less than 10% of the time.
  • From 10% to 40% of renal cell carcinomas are associated with paraneoplastic syndromes.

    • Hypertension from renin overproduction is common.
    • Stauffer syndrome (nonmetastatic hepatic dysfunction) is seen in some patients and resolves after tumor removal.
    • Hypercalcemia from parathyroid hormone–like protein produced by the tumor also may occur.
    • Erythrocytosis can occur as a result of production of erythropoietin by the tumor.

  • Staging. The most common sites of renal cell carcinoma metastasis are bone, liver, and lungs. In addition to a complete history and physical examination, it is imperative to stage RCCa prior to initiating any therapy. Blood testing should include a complete blood count, electrolytes, calcium, creatinine, and liver function tests. All patients need a chest radiograph and cross-sectional abdominal imaging [CT or magnetic resonance imaging (MRI) scan with contrast]. Radionuclide bone scan is not necessary in patients without skeletal symptoms who have normal alkaline phosphatase and serum calcium levels. The TNM (tumor, node, metastasis) staging system for RCCa is outlined in Table 35-1.
  • Imaging modalities
    • CT scan with and without intravenous contrast is the preferred diagnostic study for evaluating a renal mass. Precontrast images may be hypodense, isodense, or hyperdense compared with normal renal parenchyma; renal cell carcinomas generally enhance, but to a lesser degree than surrounding parenchyma. CT also provides staging information, including local extent of the tumor, presence of regional lymphadenopathy, and presence of distant metastatic lesions (lung, liver, or adrenal gland).
    • Ultrasonography is the modality of choice in determining whether a lesion is solid or cystic. Doppler ultrasonography is useful for evaluating vena caval involvement.
      • The Bosniak classification of renal cysts (Radiology 1991;179:307) is as follows:

        • Category I: simple cyst.




Category II: high-density cyst; thin, smooth septa; or linear calcification.
TABLE 35-1 American Joint Committee on Cancer Staging of Kidney Cancer
Stage
Tumor (T)a
Node (N)b
Metastasis (M)c
I
T1
N0
M0
II
T2
N0
M0
III
T1
N1
M0
T2
N1
M0
T3
N0, N1
M0
IV
T4
N0, N1
M0
Any T
N2, N3
M0
Any T
Any N
M1
aT1, tumor ≤7 cm in greatest dimension, limited to the kidney; T2, tumor >7 cm in greatest dimension, limited to the kidney; T3, tumor extends into major veins or invades adrenal gland or perinephric tissues, but not beyond Gerota's fascia; T3a, tumor invades adrenal gland or perinephric tissues, but not beyond Gerota's fascia; T3b, tumor grossly extends into renal vein or vena cava below diaphragm; T3c, tumor grossly extends into vena cava above the diaphragm; T4, tumor grossly extends beyond Gerota's fascia.
bN0, no regional lymph node metastasis; N1, metastasis in a single regional lymph node, 2 cm in greatest dimension; N2, metastasis in a single regional lymph node, >2 cm but not >5 cm in greatest dimension, or multiple lymph nodes, none >5 cm in greatest dimension; N3, metastasis in a lymph node >5 cm in greatest dimension.
cM0, no distant metastasis; M1, distant metastasis.




        • Category IIF (requires follow-up): multiple smooth, thin septae or thickened, nonenhancing septa; high-density cyst greater than 3 cm.
        • Category III: indeterminate lesions; numerous or thick septa, or both; thick calcification. These lesions require surgical management.
        • Category IV: high probability of malignancy with cystic component, irregular margins, and solid vascular elements. These lesions require surgical management.


    • MR scan is useful for staging renal tumors (especially in patients with renal insufficiency or allergy to contrast dye) and for detecting tumor thrombus in the renal vein and inferior vena cava.


II. Management of Renal Masses
A. Radical nephrectomy
Radical nephrectomy remains the most effective treatment modality for stage T1 and T2 disease. Radical nephrectomy involves removing the kidney outside of Gerota's fascia. Ten-year survival after nephrectomy for Robson stage I and II lesions was greater than 78% in one modern series (J Urol 1998;159:192). Laparoscopic radical nephrectomy has been shown to provide equivalent oncologic results in several single institutional reports (J Urol 2005;174:1222, J Endourol 2005;19:803, Urology 2003;62:1018). Nephron-sparing surgery (partial nephrectomy) has become the standard of care for small T1 (<4 cm) lesions (J Urol 2004;171:2181). For smaller tumors, laparoscopic partial nephrectomy, cryoablation, and radiofrequency ablation remain experimental.
B. Renal cell carcinoma is resistant to radiation and chemotherapy
Immunotherapy protocols using interferon and interleukin-2 have demonstrated increased survival after nephrectomy for metastatic renal cell carcinoma in patients with excellent functional status (J Urol 2000;163:154S).
Diseases of the Ureter
I. Ureteropelvic Junction Obstruction (UPJO)
UPJO is often a congenital anomaly that results from a stenotic segment of ureter. Acquired lesions may include tortuous or kinked ureters as a result of vesicoureteral reflux, benign tumors such as fibroepithelial polyps, or scarring as a result of stone disease, ischemia, or previous surgical manipulation of the urinary system. The role of crossing vessels (present in one third of cases) has not been firmly established, although their presence may be associated with treatment failures.

  • Presentation. Although UPJO can be a congenital problem, patients may present at any age. Common symptoms are flank pain (which may be intermittent), hematuria, infection, and, rarely, hypertension.
  • Radiographic studies help to determine the site and functional significance of the obstruction. Useful studies include IVP, diuretic renal scintigraphy, and retrograde pyelography. Ultrasound may demonstrate hydronephrosis, but this is not diagnostic of functional obstruction.
  • Open pyeloplasty is the gold standard treatment, with success rates greater than 90%. Recently, a variety of minimally invasive procedures have been developed to avoid the morbidity of open surgery. Options include laparoscopic pyeloplasty, percutaneous endopyelotomy, and ureteroscopic or retrograde endopyelotomy with a balloon-cutting device.

II. Urolithiasis
A. Epidemiology
The peak incidence of urinary calculi is in the third to fifth decades. Stones are more prevalent in men than in women. Stone incidence is increased during the late summer months. Dietary factors leading to stone formation include low water intake and high protein or oxalate (leafy green vegetable) consumption. Calcium restriction is not recommended as a means of preventing stone formation; however, a low-sodium diet may decrease calciuria. Citrus juices, particularly lemonade, may increase urinary levels of citrate, an inhibitor of stone formation (J Urol 1996;156:907). Various drugs, including high-dose vitamins C and D, acetazolamide, triamterene, and some protease inhibitors (indinavir) (Lancet 1997;349:1294), have been associated with stone formation. Disease states, such as inflammatory bowel disease, and metabolic disorders, such as type I renal tubular acidosis or cystinuria, can also contribute to stone formation.
B. Clinical features
Acute onset of severe flank pain or renal colic, often associated with nausea and vomiting, results from urinary obstruction by the stone. Common locations for stones to become impacted include the renal infundibulum, the ureteropelvic junction, the crossing of the iliac vessels, and the ureterovesical junction, which is the most constricted area through which the stone must pass. Patients may present with microscopic or gross hematuria, but 15% of patients may have no hematuria.
C. Types of calculi

  • Calcium stones make up approximately 70% of all stones. Disorders of calcium metabolism, such as increased intestinal absorption or increased renal excretion of calcium or oxalate, can cause calcium stones. Systemic disorders, such as hyperparathyroidism, sarcoidosis, immobilization (causing calcium resorption from bone), and type I renal tubular acidosis, can lead to these derangements of calcium metabolism.
  • Uric acid stones make up approximately 10% of all stones. They occur as a result of hyperuricosuria, persistently acidic pH, and low urine volumes.
  • Cysteine stones account for 4% of stones. They are caused by a defect in tubular reabsorption of cysteine that is inherited in an autosomal recessive manner. Hexagonal crystals in the urine are highly suggestive of cysteine stones.
  • Magnesium ammonium phosphate or struvite stones account for 15% of stones and are associated with urinary tract infection, commonly with urea-splitting organisms, and a chronically alkaline urinary pH (>7.2). Urinalysis may demonstrate rectangular “coffin lid” crystals.

D. Evaluation of urinary calculi

  • Urinalysis, including microscopic examination and urine culture, should be performed on all patients suspected of having calculi.

Serum electrolytes, including calcium, and creatinine levels are also part of the standard workup. In addition, uric acid levels and parathyroid hormone levels may be helpful. A CBC with differential can be obtained in patients with signs of concurrent infection.
  • Noncontrast spiral CT has replaced IVP as the diagnostic study of choice in the acute setting (J Urol 1998;160:679). For patients with suspected nephrolithiasis but atypical symptoms, CT may elucidate other causes of abdominal pain. Signs of obstruction include hydroureteronephrosis and perinephric fat stranding.
  • KUB (kidneys, ureters, bladder) should be used to monitor stone passage in patients with already documented nephrolithiasis and to evaluate whether the stone is amenable to extracorporeal shock-wave lithotripsy (ESWL).

E. Management of urinary calculi

  • Hydration. Intravenous fluids are required if the patient is nauseated and cannot take oral fluids. Normal saline usually is initiated at 150 mL/hour in appropriate patients.
  • Pain management. Patients whose pain is not adequately managed with oral analgesics require hospitalization for administration of parenteral narcotics. Parenteral nonsteroidal compounds, such as ketorolac, can be effective in reducing the pain of renal colic but should not be used in patients who may undergo lithotripsy. ESWL is contraindicated within 72 hours of administration of nonsteroidal analgesics to minimize the risk of renal hematoma.
  • Urine should be collected and strained to retrieve the stone. The stone should be analyzed for composition.
  • Any patient found to have an obstructing stone in the presence of infection or fever needs emergent decompression with percutaneous nephrostomy tube or stent placement. This situation can deteriorate quickly into a life-threatening crisis, particularly in the diabetic or immunosuppressed patient.
  • Ninety-five percent of stones 4 mm or smaller in size pass spontaneously (J Urol 1997;158:1915). Patients may be given up to 4 weeks to pass a partially obstructing stone without permanent renal damage. Patients with stones larger than 4 mm or with intractable symptoms of pain, nausea, or vomiting may need early surgical treatment to relieve obstruction with a ureteral stent, shock-wave lithotripsy, or ureteroscopy with stone ablation or retrieval.
  • Patients who have had one episode of nephrolithiasis do not require further workup. Those who have recurrent episodes require a 24-hour urine collection for volume, creatinine, pH, sodium, calcium, magnesium, phosphorous, oxalate, citrate, uric acid, and protein measurement.
  • Potassium citrate may help to prevent stone recurrence by increasing urinary citrate levels and alkalizing the urine. Uric acid stones may dissolve by increasing urinary pH, and calcium stones may be prevented with thiazide diuretics.

Diseases of the Urinary Bladder
I. Bladder Cancer
Bladder cancer is found in up to 10% of patients with microscopic hematuria.
A. Transitional cell carcinoma
Transitional cell carcinoma accounts for up to 90% of bladder tumors in the United States; squamous cell carcinoma and adenocarcinoma are less common. Transitional cell carcinoma has been linked directly to cigarette smoking, aniline dye and aromatic amine exposure, and chronic phenacetin use. Patients who have received cyclophosphamide are at increased risk for developing transitional cell carcinoma; use of the uroprotectant mesna (2-mercaptoethane sodium sulfonate) may reduce this risk as well as reduce the risk of hemorrhagic cystitis.
B. Transitional cell cancer is categorized as superficial or invasive
Staging is outlined in Table 35-2.
C. Superficial tumors
Superficial tumors are exophytic papillary lesions that do not invade the muscular bladder wall. These tumors can be treated with transurethral resection. Between 65% and 85% of superficial tumors recur; therefore, diligent follow-up is necessary. Recurrent tumors are treated with transurethral resection and intravesical therapy (bacillus Calmette-Guérin or mitomycin C). In 10% to 15% of patients with superficial bladder tumors, the tumors progress to muscle-invasive disease; their tendency to progress depends on stage and grade.
TABLE 35-2 American Joint Committee on Cancer Staging for Bladder Cancer
Stage
Tumor (T)a
Node (N)b
Metastasis (M)c
0a
Ta
N0
M0
0is
Tis
N0
M0
I
T1
N0
M0
II
T2a
N0
M0
T2b
N0
M0
III
T3a
N0
M0
T3b
N0
M0
IV
T4a
N0
M0
T4b
N0
M0
Any T
N1–3
M0
Any T
Any N
M1
aTa, noninvasive papillary carcinoma; Tis, carcinoma in situ; T1, tumor invades subepithelial connective tissue; T2, tumor invades muscle; T2a, tumor invades superficial muscle (inner half); T2b, tumor invades deep muscle (outer half); T3, tumor invades perivesical tissue; T3a, microscopically; T3b, macroscopically (extravesical mass); T4, tumor invades any of the following prostate, uterus, vagina, pelvic wall, or abdominal wall; T4a, tumor invades prostate, uterus, or vagina; T4b, tumor invades pelvic wall or abdominal wall.
bN0, no regional lymph node metastasis; N1, metastasis in a single lymph node ≤2 cm in largest dimension; N2, metastasis in a single lymph node >2 cm but not >5 cm in greatest dimension, or multiple lymph nodes, none >5 cm in greatest dimension; N3, metastasis in a lymph node >5 cm in greatest dimension
cM0, no distant metastasis; M1, distant metastasis.
D. Muscle-invasive transitional cell carcinoma
Muscle-invasive transitional cell carcinoma is treated with radical cystectomy and urinary diversion. Radical cystectomy involves radical cystoprostatectomy (removal of bladder, prostate, and possibly urethra) in the male and anterior exenteration (removal of bladder, urethra, uterus, cervix, and anterior wall of vagina) in the female. Appropriate metastatic evaluation for patients with invasive bladder cancer includes chest radiograph, CT urogram, bone scan, and liver function tests. Despite this aggressive management, only 50% of patients with invasive bladder cancer are rendered completely free of tumor because many have occult metastases at the time of surgery.
E. Chemotherapy
Chemotherapy is the treatment of choice for locally advanced or metastatic bladder cancer. MVAC [methotrexate, vinblastine, doxorubicin (Adriamycin), and cis-platinum] has been the traditional regimen, but recent studies have shown the combination of gemcitabine and cis-platinum to have equivalent oncologic efficacy with an improved side effect profile (J Clin Oncol 2005;23:4602).
Diseases of the Prostate
I. Prostate Cancer

  • Prostate examination. Digital rectal examination (DRE) of the prostate is an important part of the physical examination. The normal prostate is chestnut sized and measures 3.5 cm wide at the base, 2.5 cm long, and 2.5 cm deep; it weighs approximately 20 g. The prostate should feel smooth and have the consistency of the contracted thenar eminence of the thumb. The prostate is best examined when the patient is standing with the knees slightly flexed and elbows resting on a table or in the lateral decubitus position with the hips flexed.

Prostate nodules usually are small (pea sized) or larger firm areas within the peripheral zone of the prostate. Fifty percent of prostate nodules represent prostate cancer and must be evaluated with transrectal ultrasonography (TRUS) and prostate biopsy. Serum prostate-specific antigen (PSA) is a more sensitive test than DRE for detection of prostate cancer, but the tests should be used together to maximize cancer detection (J Urol 1994;151:1283).
  • Prostate cancer is the most common noncutaneous malignancy in American men and the second leading cause of cancer death. Twenty percent of men with prostate cancer die of the disease. Prostate cancer rarely causes symptoms until it becomes locally advanced or metastatic.
  • Current American Urological Association and American Cancer Society guidelines recommend that men age 50 years and older begin prostate cancer screening with a yearly DRE and PSA measurement. African American men and men with a family history should begin screening at age 45 years (Oncology 2000;14:267). Abnormalities in either the DRE (manifest as indurated nodules) or the PSA greater than 2.5 ng/mL should be evaluated by TRUS and needle biopsy of the prostate (National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology 2006, http://www.nccn.org).
  • Appropriate staging workup includes DRE and PSA. Table 35-3 outlines current staging for prostate cancer. Bone scan is not necessary for patients with well-differentiated or moderately differentiated tumors and a PSA less than 10. CT is of limited value for patients with well-differentiated or moderately differentiated tumors and a PSA less than 20.
  • Prostate cancer is graded by the Gleason scoring system, which is based on the histologic architectural pattern of the prostate gland. The two most predominant architectural patterns are assigned a grade 1 through 5 (1 being the most differentiated and 5 being the least differentiated). The two patterns are added together to give the overall Gleason score. The Gleason score is reported as the most prevalent grade plus the second most prevalent grade, followed by the sum (e.g., 4 + 3 = 7). Well-differentiated tumors have a Gleason sum of 2 to 4, moderately differentiated tumors have a sum of 5 or 6, and poorly differentiated tumors have a sum of 8 to 10. For Gleason sum 7, patients with 3 + 4 are considered moderately differentiated, and those with a 4 + 3 are considered poorly differentiated.

TABLE 35-3 American Joint Committee on Cancer Staging of Prostate Cancer
Stage
Tumor (T)a
Node (N)b
Metastasis (M)c
I
T1a
N0
M0d
II
T1a
N0
M0
T1b
N0
M0
T1c
N0
M0
T2a,T2b
N0
M0
III
T3
N0
M0
IV
T4
N0
M0
Any T
N1
M0
Any T
Any N
M1
aT1, clinically inapparent tumor neither palpable nor visible by imaging; T1a, tumor incidental histologic finding in ≤5% of tissue resected; T1b, tumor incidental histologic finding in >5% of tissue resected; T1c, tumor identified by needle biopsy (e.g., because of elevated prostate-specific antigen levels); T2, tumor confined within the prostate; T2a, tumor involves one lobe; T2b, tumor involves both lobes; T3, tumor extends through the prostatic capsule; T3a, extracapsular extension (unilateral or bilateral); T3b, tumor invades seminal vesicles; T4, tumor is fixed or invades adjacent structures other than the seminal vesicle(s) structures, bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall.
bN0, no regional lymph node metastasis; N1, metastasis in regional lymph node(s).
cM0, no distant metastasis; M1, distant metastasis; M1a, nonregional lymph node(s); M1b, bone(s); M1c, other site(s).
dIncludes only well-differentiated (Gleason grade 2–4) tumors.
 
  • Treatment options for men with organ-confined prostate cancer include radical prostatectomy, external-beam radiation therapy, and interstitial radiotherapy (brachytherapy).
    • Radical prostatectomy compared to active surveillance offers a 44% relative reduction in 10-year prostate cancer related mortality, a 26% relative reduction in 10-year overall mortality, a 40% reduction in the risk of distant metastasis, and a 67% relative reduction in local progression in men with early prostate cancer (N Engl J Med 2005;352:19).
    • External-beam radiotherapy with delivery of 6,500 to 7,500 cGy achieves disease-free rates of 45% to 85% for localized disease (N Engl J Med 1994;331: 996). High-risk patients benefit from adjuvant hormonal therapy in addition to radiotherapy (Lancet 2002;360:103, JAMA 2004;292:821).
    • Technical improvements in dosimetry and implantation combined with reports of low morbidity have led to a renewed interest in brachytherapy. Some authors have suggested that brachytherapy alone may have a higher rate of PSA progression than other treatment modalities (Urology 1998;51:884).
    • Hormonal therapy with either bilateral orchiectomy or luteinizing hormone–releasing hormone agonists usually is reserved for men with locally advanced or metastatic disease.
    • Active surveillance may be appropriate for men with low-grade prostate cancer (J Urol 2004;172:S48). The optimal form of treatment for clinically localized prostate cancer has not been conclusively determined.


II. Prostatitis
Prostatitis is a diagnosis that spans a spectrum of disease entities. The classification and diagnostic criteria for the different forms of prostatitis recently have been changed in an effort to standardize diagnosis to improve research and clinical treatment.
A. Signs and symptoms of urinary tract infection
Signs and symptoms of urinary tract infection mark acute bacterial prostatitis; many patients have significant voiding complaints, fevers, and malaise. DRE reveals a tender, boggy prostate. Repeat exams should be minimized to avoid spread of infection. Fluoroquinolones are the mainstays of treatment and should be continued for 4 to 6 weeks. Patients with high fevers may require admission for intravenous antibiotics. Drainage of the urinary bladder via a suprapubic tube or a small urethral catheter may be required for patients in urinary retention.
B. Chronic bacterial prostatitis
Chronic bacterial prostatitis is differentiated from other categories by the presence of documented recurrent bacterial infection of expressed prostatic secretions, postprostatic massage urine, or semen. Treatment is with antibiotics; fluoroquinolones have excellent prostatic penetration.
III. Benign Prostatic Hyperplasia (BPH)
Benign Prostatic Hyperplasia (BPH) is a histologic diagnosis and represents an increase in the number of epithelial and stromal elements of the prostate. Men with BPH and benign prostatic enlargement (BPE) on examination do not necessarily have lower urinary tract symptoms (LUTS).
A. Evaluation
Common signs and symptoms of BPH include hesitancy, decreased force of stream, frequency, urgency, postvoid dribbling, double voiding, incomplete bladder emptying, and nocturia. LUTS is a symptom complex of obstructive and irritative voiding problems. Bladder outlet obstruction (BOO) is objective evidence of obstructive voiding problems and can include a demonstrated decrease in maximum urinary flow rate, increase postvoid residual urine (PVR), and cystoscopic findings of obstruction.
B. Treatment

  • Medical Therapy. BPH is most commonly treated medically with α-blockers, such as doxazosin, terazosin, tamsulosin, and alfuzosin. Another class of medications, 5-α-reductase inhibitors, such as finasteride or dutasteride, are also used to treat BPH. The Medical Therapy of Prostatic Symptoms Trial (MTOPS) showed that combination therapy with an α-blocker and a 5-α-reductase inhibitor reduced the risk of overall clinical progression of BPH significantly more than did treatment with either drug alone (N Engl J Med 2003;349:2387).

Surgical Therapy. If medications are ineffective, intervention with some form of prostatectomy is warranted. Microwave thermotherapy is an office-based, transurethral procedure that uses heat energy to cause tissue necrosis, decreased prostate volume, and improved voiding. The gold standard is the transurethral prostatectomy (TURP), but transurethral resection using various forms of laser energy is being more commonly performed.
IV. Urinary Retention
Urinary Retention may result from BPH, prostate cancer, or urethral stricture disease. Retention also can be associated with pelvic trauma, neurologic conditions, or various medications or the postoperative setting.
A. Evaluation
A history usually elicits the cause of retention. Patients with BPH who are treated with decongestants containing an α-agonist may develop urinary retention from increased smooth-muscle tone at the bladder neck and the prostate.
B. Physical examination
Physical examination reveals a distended lower abdomen. Prostatic enlargement is common on DRE. Serum electrolytes including creatinine level, urinalysis, and urine culture should be obtained. Serum PSA concentration obtained during acute urinary retention often is spuriously elevated and is best measured at least 4 to 6 weeks after the acute event.
C. Treatment

  • Bladder decompression with a Foley catheter is the mainstay of treatment. The proper technique of urethral catheter placement involves passing the catheter to the hub and inflating the balloon only after the return of urine.
  • When a standard Foley catheter cannot be passed easily, sterile 2% viscous lidocaine can be injected through the urethra. This anesthetizes and relaxes the sphincter, allowing gentle passage of a 16- to 22-French Coudé tip catheter. The catheter is passed gently with the tip directed upward. If the Coudé tip catheter does not pass easily, a urology consultation is required.
  • Catheterization should not be attempted when a urethral injury is suspected. Urethral stricture requires calibration and dilation or placement of a suprapubic tube by a urologist. Urinary clot retention usually requires bladder irrigation.
  • Patients should be monitored for postobstructive diuresis, especially if the patient is azotemic. This is a physiologic response to a hypervolemic state. Occasionally, it can become a pathologic diuresis and may warrant hospital observation, with fluid and electrolyte replacement. Five-percent dextrose in 0.45% saline should be used for hydration. Urine output greater than 200 mL/hour for more than 2 hours should be replaced with 0.5 mL of intravenous 0.45% saline for each 1 mL of urine. Electrolytes should be checked every 6 hours initially and replaced as needed.

Diseases of the Penis
I. Priapism
Priapism is a persistent erection that is not associated with sexual stimulation or that continues after orgasm. The corpora cavernosa are affected, but the corpus spongiosum usually is spared. Priapism can be classified as low flow or high flow.
A. Ischemic priapism
Ischemic priapism is characterized by little or no blood flow to the corpora and is considered a urologic emergency. Symptoms include pain and tenderness. History should elicit various etiologies of priapism including: (1) hematologic abnormalities, such as sickle cell disease; (2) drugs, including antihypertensives (hydralazine, guanethidine, prazosin), anticoagulants, antidepressants and psychotropic agents (especially Trazadone), alcohol, marijuana, cocaine, and intracavernous injection of vasoactive substances (prostaglandin E1, phentolamine, papaverine) used to treat erectile dysfunction; and (3) neoplasm (especially leukemia), with venous occlusion, stasis, and emboli. Physical examination reveals firm corpora and a flaccid glans. Stasis, thrombosis, fibrosis, and scarring of the corpora cavernosa eventually can result in erectile dysfunction if priapism is not treated promptly. Of note, phosphodiesterase type 5 (PDE5) inhibitors, which are used for the treatment of erectile dysfunction (see Section II.E.2), are rarely associated with ischemic priapism.
B. Treatment
Treatment (American Urological Association Clinical Guidelines 2003)
  • First-line treatment involves corporal irrigation and aspiration of old blood from the corpora via a 21-gauge needle.
  • An α-adrenergic agent (phenylephrine, 250 to 500 µg) can then be injected. The solution is prepared by mixing 1 mL of phenylephrine (10 mg/mL) in 19 mL of sterile normal saline. Each milliliter contains 500 µg of phenylephrine. Doses can be repeated every 5 to 10 minutes. Patients should be monitored for the possible hemodynamic effects of phenylephrine. Topical or subcutaneous injection of lidocaine before therapeutic injection or irrigation can be helpful for patient comfort. Injections and aspiration should be performed laterally at the 3 o'clock and 9 o'clock positions to avoid the dorsal blood supply of the penis.
  • For patients with sickle cell disease, treatment involves aggressive hydration, supplemental oxygen, and blood transfusion if the hematocrit is low.
  • If evacuation of old blood and injection of a-adrenergic agents fails, surgical shunting should be considered. Distal corpus cavernosum-to-glans penis (corpus spongiosum) shunting (Winter or Al-Ghorab shunt) is the initial surgical treatment. If distal shunting fails, then a more proximal side-to-side cavernosospongiosal shunt (Quackel shunt) or cavernosaphenous shunt may be necessary.

C. High-flow priapism
High-flow priapism is a nonischemic state usually brought about by perineal or genital trauma. A traumatic pudendal arterial fistula or cavernosal artery laceration may give rise to a high-flow state. Diagnosis is confirmed by aspiration of bright-red, well-oxygenated blood. Blood gas analysis can be helpful in differentiating low-flow priapism from high-flow priapism. Treatment is accomplished by embolization of the ipsilateral branch of the pudendal artery.
II. Erectile Dysfunction (ED)
Erectile Dysfunction (ED) recently has received increasing attention from the public and lay media as a result of new treatment modalities. ED affects 52% of men aged 40 to 70 years of age according to the Massachusetts Male Aging Study; incidence increases with age, but the degree of mild ED remains fairly constant from age 40 to 70 years. Unfortunately, only 20% of men with ED discuss this condition with a health care provider. The overwhelming majority of men have an organic etiology of their ED.
A. Initial evaluation
Initial evaluation entails a frank discussion of the complaint to define the true sexual disorder; one must differentiate ED from premature ejaculation, inability to climax, infertility, and loss of libido. Unlike men with organic ED, those with psychogenic ED have sudden onset and continue to have nocturnal erections. Loss of libido may signal hormonal disturbances. A complete history and physical examination are done to elicit possible underlying causes of ED, including heart disease, hypertension, diabetes, dislipidemia, renal insufficiency, and endocrine disease (hypogonadism). Smokers have a twofold higher incidence of ED. Previous pelvic or penile surgery may be associated with ED.
B. Attention should be paid to medications
Attention should be paid to medications, such as antihypertensives [central-acting agents (clonidine), α-adrenergic blocking agents (prazosin), β-blocking agents], antipsychotics, tricyclic antidepressants, and histamine (H2) blockers, that may be associated with ED. Heavy use of alcohol and social drugs can also lead to ED.
C. Physical examination
Physical examination should focus on genital development and signs of endocrinologic or neurologic abnormalities.
D. Appropriate laboratory testing
Appropriate laboratory testing includes serum chemistries, creatinine, CBC, urinalysis, and, when indicated, a limited hormonal evaluation (testosterone and prolactin). In addition, screening for diabetes and hypercholesterolemia should be done. For the majority of patients, ED is multifactorial, and no single cause is identified.
E. Treatment
The initial recommendation should be for lifestyle modification and management of the underlying disease. Smoking cessation, diet modification, and exercise have all been shown to improve erectile function and overall health. It is appropriate to counsel patients about available nonsurgical and surgical options for treatment and to encourage treatment until a satisfactory solution is found.
Hormone replacement. Exogenous testosterone is available in a variety of delivery methods, including parenteral preparations and transdermal therapy. Liver function tests should be monitored. This treatment is best suited for patients with a low libido and documented hypogonadism. The effect of testosterone on erectile function is variable.
  • Oral therapies. PDE5 inhibitors should be offered as first-line therapy. Medications include sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). PDE5 inhibitors inhibit the breakdown of cyclic guanosine monophosphate, allowing smooth-muscle relaxation in the corpus cavernosum. Side effects include headache, facial flushing, and dyspepsia. PDE5 inhibitors are contraindicated in patients who are taking nitrates because of a synergistic effect that results in hypotension.
  • Intracavernosal therapy. Injection of vasoactive medications, such as alprostadil (prostaglandin E1), directly into the corpus cavernosum is effective in 70% to 80% of patients. Side effects are pain with injection, hematoma or ecchymosis, and priapism. An intraurethral alprostadil suppository is also available and is effective in some men.
  • Vacuum erection device (VED). For men who fail or are not candidates for medical therapy, a vacuum pump is efficacious, but many couples find it cumbersome and uncomfortable. Patients with difficulty in maintaining an erection due to cavernosal venous insufficiency may benefit from a constriction band.
  • Surgical options. For patients who are refractory to noninvasive therapy, consideration may be given to a surgically placed penile implant. These devices have a high degree of success, and they are placed via small genital incisions. There are potential complications, such as infection (2%) and mechanical malfunction (2%).

Diseases of the Scrotum and Testicles
I. Management of Scrotal Emergencies
Acute scrotal pathology can result in significant morbidity, testicular loss, and infertility. The diagnosis can be difficult to make and may require scrotal exploration.
A. Testicular torsion
Testicular torsion develops most often in the peripubertal (12 to 18 years old) age group, although it can occur at any age.
  • The clinical picture is one of acute onset of testicular pain and swelling, commonly associated with nausea and vomiting. Some patients give a history of a prior episode that spontaneously resolved (intermittent torsion). There usually is no history of voiding complaints, dysuria, fever, or exposure to sexually transmitted diseases.
  • Physical examination reveals an extremely tender, swollen testicle high riding in the scrotum with a transverse lie. The cremasteric reflex (elicited by stroking the inner thigh) is absent on the affected side. In contrast to epididymitis, elevation of the scrotum does not provide relief of pain (Prehn sign) in torsion. Normal urinalysis and the absence of leukocytosis help to rule out epididymitis. Testicular torsion is a clinical diagnosis, and if enough suspicions exist, the patient needs to be explored without delay.
  • When the clinical diagnosis is equivocal or suspicion is low, color Doppler ultrasound can help to confirm or exclude the diagnosis. Doppler ultrasound has a low false-positive rate and a high sensitivity and specificity (Pediatrics 2000;105:604).
  • Treatment should not be delayed to obtain imaging. If testicular torsion is suspected, urgent scrotal exploration is indicated. Manual detorsion of the testicle may be attempted in the emergency room, but bilateral orchiopexy is still indicated. Typically, the testicle is detorsed by rotating from a medial to lateral direction. Testicular viability is a function of the reestablishment of perfusion (Table 35-4). Contralateral testicular fixation should be performed at the time of surgery.

B. Torsion of testicular appendage (appendix testis)
Torsion of testicular appendage (appendix testis) can present with symptoms similar to those of torsion of the testicle, usually in a prepubertal boy. The onset commonly is over 12 to 24 hours.
Extreme tenderness over the appendage exists, usually on the superior aspect of the testicle. The “blue dot” sign may be present when the ischemic appendage can be seen through the scrotal skin. The testicle has a normal position and lie. Careful examination reveals that the testicle and the epididymis are not diffusely tender or swollen. The cremasteric reflex usually is present. Imaging studies may be necessary if the clinical diagnosis is unclear.
TABLE 35-4 Rate of Salvage in Testicular Torsion
Duration of ischemia (hr)
Salvage rate (%)
0–6
85–97
6–12
55–85
12–24
20–80
>24
<10
Adapted from American Urological Association. Torsion of the Testis: Changing Concepts (AUA Update Series IX). Linthicum, MD: American Urological Association; 1990.

  • Torsion of the testicular appendage usually is managed expectantly. Pain is best controlled with anti-inflammatory agents and gradually resolves over 7 to 14 days.

C. Mild epididymitis
Mild epididymitis usually presents with a 1- to 2-day onset of unilateral testicular pain and swelling associated with dysuria or urethral discharge.
  • Typically, the findings include a painful, indurated epididymis and pyuria. Urinalysis, urine culture, and CBC count are obtained. When clinically indicated, urethral swabs for gonococci and chlamydiae are sent for culture.
  • With appropriate antibiotic coverage, these patients can be managed as outpatients. For patients in whom the etiology is gonococcal or chlamydial, ceftriaxone (125 to 250 mg intramuscularly) is given in the emergency room, followed by doxycycline (100 mg orally two times a day for 7 days). Azithromycin, 1 g orally as a one-time dose, is as effective as doxycycline in the treatment of chlamydial infections (MMWR 1998;47:51). In older men (>35 years of age), enterobacteria are more common, and a fluoroquinolone, such as ciprofloxacin (500 mg orally two times a day), provides broad coverage until culture sensitivities can be obtained. Nonsteroidal analgesics and scrotal elevation can reduce inflammation and provide symptomatic relief.
  • Moderate to severe cases of epididymitis may require hospital admission. Symptoms usually have been present for several days. Fever and leukocytosis are present. Broad-spectrum antibiotics and supportive measures of bedrest with scrotal elevation should be instituted. Ultrasonography can be useful to rule out abscess formation and assess testicular perfusion.

D. Fournier gangrene
Fournier gangrene is a severe polymicrobial soft-tissue infection involving the genitals and perineum. Although the term Fournier gangrene usually is applied to men, necrotizing fasciitis of this area can occur in women. Prompt diagnosis and institution of treatment may be lifesaving. Roughly 25% of the patients have a genitourinary source, 25% have an anorectal source, up to 10% have an intra-abdominal source, and nearly 40% have an unidentified source. Diabetic, alcoholic, and other immunocompromised patients appear to be more susceptible. The clinical course is one of abrupt onset with pruritus, rapidly progressing to edema, erythema, and necrosis, often within a few hours. Fever, chills, and malaise are accompanying signs.
  • Physical examination reveals edema and erythema of the skin of the scrotum, phallus, and perineal area. This may progress rapidly to frank necrosis of the skin and subcutaneous tissues, with extension to the skin of the abdomen and back, reaching as high as the clavicles and down the thighs. Crepitus in the tissues suggests the presence of gas-forming organisms.

Laboratory evaluation should include a CBC, serum electrolytes, creatinine, arterial blood gas, coagulation parameters, urinalysis, urine, and blood cultures. A KUB plain film may reveal subcutaneous gas.
  • The patient should be stabilized and prepared emergently for the operating room. Broad-spectrum antibiotics that are active against both aerobic and anaerobic organisms should be started immediately. Aerobic and anaerobic wound cultures are usually polymicrobial.
  • Wide débridement is required, with aggressive postoperative support. The testicles are often spared because they have a blood supply discrete from the scrotum; orchiectomy is rarely indicated. Wound closure and dermal coverage often is an extensive process, and recovery requires intense physical therapy and wound care. Despite improvements in critical care, antibiotics, and surgical technology, mortality ranges from 3% to 45% (Br J Surg 2000;87:718).

II. Nonacute Scrotal Masses
A. Hydroceles
Hydroceles generally are asymptomatic fluid collections around the testicle that transilluminate. Ultrasound evaluation is recommended to rule out serious underlying causes such as testicular malignancies. If hydroceles do enlarge and become symptomatic, they can be repaired by a variety of transscrotal techniques. Hydroceles in infants may be associated with a patent processus vaginalis; parents give a history of intermittent scrotal swelling. These hydroceles usually resolve by 1 year of age. Those that persist can be repaired by an inguinal approach.
B. Spermatoceles
Spermatoceles are benign cystic dilations involving the tail of the epididymis or proximal vas deferens.
C. Varicoceles
Varicoceles are abnormal tortuosities and dilations of the testicular veins within the spermatic cord. On physical examination, they feel like a “bag of worms.” A varicocele may diminish in size when the patient is supine. Because the left gonadal vein drains directly into the renal vein, varicoceles are much more common on the left side. Right-sided varicoceles may be associated with obstruction of the inferior vena cava. Varicoceles are the most common surgically correctable cause of male infertility; however, most men with varicoceles remain fertile. Varicocele repair results in improved semen quality in approximately 70% of patients. Surgical treatment of varicoceles is indicated for diminished testicular growth in adolescents, infertility, or significant symptoms. Any patient who presents with a new-onset varicocele later in life warrants retroperitoneal imaging to rule out a malignancy causing venous obstruction.
III. Testicular Tumors
Testicular Tumors are the most common solid tumors in 15- to 35-year-old men. The estimated lifetime risk for testicular malignancy is 1 in 500. Owing to improved multimodality therapy, overall 5-year survival for testis cancer is now 95%.
A. The typical clinical finding is a painless testicular mass
The typical clinical finding is a painless testicular mass, although one third of patients may present with pain. Pulmonary or gastrointestinal complaints or the presence of an abdominal mass may reflect advanced disease. Scrotal sonography is mandatory; seminomas appear as a hypoechoic lesion, and nonseminomatous tumors appear inhomogeneous. α-Fetoprotein, β-human chorionic gonadotropin, and lactic acid dehydrogenase are serum tumor markers that help to identify the tumor type and completely stage the tumor. The markers are used to monitor the effectiveness of therapy and to screen for recurrence.
B. Staging of testicular tumors
Staging of testicular tumors is outlined in Table 35-5. Serum tumor markers have recently been added to the staging system.
C. Initial therapy
Initial therapy for all testicular tumors is radical inguinal orchiectomy. The type of tumor and the stage of the disease determine further therapy.
  • Seminomas constitute 60% to 65% of germ-cell tumors. Low-stage seminomas are treated with adjuvant radiation therapy to the retroperitoneum. Advanced disease is usually treated with a platinum-based chemotherapy regimen.

Nonseminomatous tumors include the histologic types of embryonal carcinoma, teratoma, choriocarcinoma, and yolk sac elements, alone or in combination. Nonseminomatous tumors are more likely to present with advanced disease. Patients with clinically negative retroperitoneal nodes with normal tumor markers are treated with retroperitoneal lymph node dissection, prophylactic chemotherapy, or close observation. Patients with high-stage disease with elevated markers receive platinum-based chemotherapy followed by retroperitoneal node dissection if there is residual disease.
TABLE 35-5 American Joint Committee on Cancer Staging of Testicular Cancer
Stage
Tumor(T)a
Node (N)b
Metastasis (M)c
Serum tumor markers (S)
0
Tis
N0
M0
S0
IA
T1
N0
M0
S0
IB
T2–4
N0
M0
S0
IS
Any T
N0
M0
S1–3
IIA
Any T
N1
M0
S0
Any T
N1
M0
S1
IIB
Any T
N2
M0
S0
Any T
N2
M0
S1
IIC
Any T
N3
M0
S0
Any T
N3
M0
S1
IIIA
Any T
Any N
M1a
S0
Any T
Any N
M1a
S1
IIIB
Any T
Any N
M0
S2
Any T
Any N
M1a
S2
IIIC
Any T
Any N
M0
S3
Any T
Any N
M1a
S3
Any T
Any N
M1b
Any S
 
Serum tumor markers
Lactate dehydrogenase
Human chorionic gonadotropin (mlU/mL)
α-Fetoprotein (ng/mL)
S0
≤Normal
≤Normal
≤Normal
S1
<1.5 × N
<5,000
<1,000
S3
1.5–10 × N
5,000–50,000
1,000–10,000
S3
>10 × N
>50,000
>10,000
aTis, intratubular germ-cell neoplasia; T1, limited to testis; T2, beyond tunica albuginea or into epididymis; T3, invades spermatic cord; T4, invades scrotum.
bN0, no node metastasis; N1, one node metastasis, <2 cm; N2, one node metastasis, 2–5 cm, or multiple nodal metastasis, each <5 cm; N3, node metastasis >5 cm.
cM0, no metastasis; M1, nonregional nodal or pulmonary metastasis; M2, nonpulmonary visceral metastasis.
Genitourinary Trauma
Genitourinary injuries should be identified during the secondary survey after life-threatening injuries have been addressed and initial resuscitation has been undertaken.
I. Renal Injury
Renal Injury is a component of approximately 10% of abdominal traumas. Blunt trauma accounts for 80% to 90% of renal injuries. Penetrating trauma occurs as a result of gunshot wounds or stab wounds and accounts for 10% to 20% of renal injuries. The grading system for renal injuries is shown in Table 35-6.
  • Blunt renal trauma should be suspected in patients with abdominal tenderness, lower rib fractures, vertebral fractures, or flank contusions.

Microscopic hematuria (>3 RBCs per high-power field) or gross hematuria is present in more than 95% of patients with a renal injury. A voided specimen is best for urinalysis, but if the patient cannot void or is unconscious and no blood is at the meatus, a well-lubricated urethral catheter should gently be passed.
TABLE 35-6 Renal injury scale of the American Association for the Surgery of Trauma
Renal injury scale
Injury
Description
I
Contusion
Microscopic or gross hematuria; urologic studies normal
Hematoma
Nonexpanding perirenal hematoma confined to the renal retroperitoneum
II
Hematoma
Subcapsular, nonexpanding without parenchymal laceration
Laceration
<1 cm parenchymal depth of renal cortex without urinary extravasation
III
Laceration
>1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
IV
Laceration
Parenchymal laceration extending through the renal cortex, medulla, and collecting system
Vascular
Main renal artery or vein injury with contained hemorrhage
V
Laceration
Completely shattered kidney
Vascular
Avulsion of renal hilum that devascularizes the kidney

  • All patients with gross hematuria and blunt trauma should be evaluated with a CT scan using intravenous contrast. If the patient is stable, 10-minute-delayed imaging is helpful to evaluate for collecting system injuries. Patients with microscopic hematuria and shock (systolic blood pressure <90 mm Hg) should be imaged with a CT scan after they are stabilized. Patients with microscopic hematuria, no shock, and no evidence of significant deceleration or renal injury do not need radiographic evaluation of their urinary system (J Urol 1989;141:1095).
  • The degree of hematuria does not correlate with the severity of the injury (J Urol 1978;120:455), and any patient with a suspected renal injury due to rapid deceleration requires radiographic evaluation. Disruption of the ureteropelvic junction should be considered in children with deceleration or hyperextension injuries.
  • The majority of blunt renal injuries can be managed conservatively; fewer than 10% of blunt renal injuries require surgery (World J Urol 1999;17:71).
  • Penetrating renal trauma with microscopic hematuria (>3 RBCs per high-power field) or gross hematuria requires radiographic assessment with CT scan or an IVP. Preferably, this is done before exploration to evaluate the injured kidney and to confirm function of the contralateral kidney. The presence of a normal contralateral kidney may influence the surgeon's decision (repair vs. nephrectomy) on management of the injured kidney. Intraoperative palpation of a contralateral kidney may be misleading.
  • A high-dose, single-shot IVP with a 2-mL/kg bolus injection of contrast followed by a single film at 10 minutes can be performed in the trauma suite or in the operating room without interfering with other critical elements of the trauma evaluation and resuscitation.
  • Absolute indications for intraoperative renal exploration include hemodynamic instability, expanding or pulsatile perirenal mass, or injury to the renal pelvis or ureter (J Trauma 2005;59:491).

II. Ureteral Injuries
Ureteral Injuries account for approximately 3% of all urologic traumas. A high index of suspicion often is necessary to make the diagnosis, and many ureteral injuries have a delayed presentation.
The most common scenario is penetrating trauma with multiple associated injuries. The absence of gross or microscopic hematuria has been documented in 30% of patients.

  • Radiographic findings include extravasation and, more commonly, delayed function; proximal dilation; and deviation of the ureter. A CT may demonstrate medial extravasation; delayed images are necessary to assess ureteral patency. Retrograde pyelography is the most sensitive diagnostic tool but may be difficult to obtain in the setting of acute trauma.
  • Adequately visualizing the ureter during laparotomy is important for diagnosing ureteral injury; intravenous or intraureteral injection of indigo carmine or methylene blue may help to assess the integrity of the urothelium.
  • For purposes of determining the type of repair, the ureter is divided into thirds.

    • Injuries to the distal one third of the ureter are best managed by ureteral reimplantation. Additional length to provide a tension-free anastomosis may be gained by using a Psoas hitch and, if necessary, a Boari bladder flap.
    • Injuries of the middle or upper third of the ureter are best managed by ureteroureterostomy. An omental wrap may be used to protect the repair. Stents and drains are recommended for all ureteral repairs (World J Urol 1999;17:78).


III. Bladder Injuries
Bladder Injuries result from blunt trauma, penetrating trauma, and iatrogenic injury during surgical procedures.
  • Ninety-five percent of bladder injuries present with gross hematuria (Urol Clin North Am 2006;33:676). Anyone with a history of blunt or penetrating trauma, gross hematuria, and difficulty in urinating should be evaluated with a cystogram.
  • Cystogram. A Foley catheter is placed if a urethral injury is not suspected (see Section IV). A scout film is obtained. Standard radiographic contrast is diluted to a 50:50 mix with saline and is infused under gravity. When 100 mL have been instilled, an anteroposterior radiograph is taken. If no extravasation is seen, the bladder is filled to 350 mL or until the patient experiences a strong urge to void under gravity, and an anteroposterior and oblique radiograph is obtained. A postdrainage film is mandatory.
  • Upper tract imaging can then be done. If a CT scan is obtained, a CT cystogram may be substituted for a plain radiographic or fluoroscopic cystogram. The bladder should be filled retrograde by gravity via an indwelling Foley catheter with 350 mL of dilute (3% to 5%) contrast. Postdrainage films are not necessary; merely clamping the Foley to allow bladder filling with excreted contrast does not constitute an adequate study. An IVP or CT scan alone is not adequate to evaluate bladder trauma.
  • Management

    • All patients with penetrating trauma to the bladder and intraperitoneal extravasation of contrast require surgical exploration and repair of the bladder (Urol Clin North Am 2006;33:67).
    • Often, patients with blunt trauma and extraperitoneal extravasation of contrast can be managed nonoperatively with catheter drainage for 10 days. A cystogram should be performed prior to catheter removal.


IV. Genital and Urethral Injuries

  • Urethral injuries occur in 5% of patients with pelvic fractures. Posterior urethral injuries involve the prostatic and membranous urethra to the level of the urogenital diaphragm. These injuries are caused mainly by blunt trauma.
  • Urethral injury should be suspected when blood is at the meatus or the mechanism of injury is such that urethral injury might have occurred. Physical examination in patients with urethral injury may reveal penile and scrotal edema and ecchymosis. Rectal examination can reveal a high-riding prostate or boggy hematoma in the expected position of the prostate.

If a urethral injury is suspected, a retrograde urethrogram must be performed prior to Foley catheter placement. It is performed by placing a 14- or 16-French Foley catheter into the urethra without lubrication so that the balloon is 2 to 3 cm beyond the meatus. The balloon is inflated with 1 to 2 cc to seat it in the fossa navicularis. With the patient in a 30-degree oblique position, 25 to 30 mL of half-strength contrast medium is injected through the catheter. The radiograph is exposed when the contrast is nearly completely injected. If the urethra is normal, the balloon can be deflated, the catheter advanced into the bladder, and a cystogram performed.

  • Anterior urethral injuries include injuries to the bulbous and penile urethra distal to the urogenital diaphragm. Straddle injuries and penetrating trauma are the most common causes of these types of injuries. Injuries contained by Buck's fascia often have a characteristic “sleeve of penis” pattern, whereas urethral or penile injuries in which Buck's fascia is disrupted are contained by the Colles fascia and have a “butterfly” appearance on the perineum.
  • Posterior ureteral injuries can be managed by primary endoscopic realignment and delayed repair. Unstable patients require suprapubic tube placement and realignment when stable. These injuries are often associated with formation of urethral strictures and with impotence (Urol Clin North Am 2006;33:87).
  • Minor penile lacerations and contusions can be managed in the emergency room. Serious blunt or penetrating trauma with injury to the corpus cavernosum require surgical exploration, débridement, and repair of the corporal injury. A retrograde urethrogram or flexible cytoscopy is necessary to rule out urethral injury. Broad-spectrum antibiotics should be given, particularly in human bite injuries.
  • Testicular injury may occur as a result of blunt or penetrating trauma. History and physical examination are the keys to diagnosis of testicular rupture. The presentation is marked by acute and severe pain, often with associated nausea and vomiting. Physical examination may reveal a hematoma or ecchymosis of overlying skin. All penetrating scrotal gunshot wounds deep to the dartos fascia require surgical exploration. Ultrasonography can help to diagnose testicular injury associated with blunt trauma with a 100% sensitivity and a specificity of 93.5% (J Urol 2006;175:175). The orchiectomy rate is less than 10% for ruptured testicles explored within 72 hours after injury. Repair consists of hematoma evacuation, débridement of the necrotic tubules, and closure of the tunica albuginea (World J Urol 1999;17:101).
  • Scrotal avulsion and skin loss are most often a result of motor vehicle accidents. Because of the redundancy and vascularity of scrotal skin, a variety of options are available for local flaps and coverage of the testicles. Wounds should be copiously irrigated and débrided; clean wounds may be closed in layers, whereas grossly contaminated wounds should be cleaned and packed with sterile gauze dressings.

Submit "35 Urologic Surgery" to Digg Submit "35 Urologic Surgery" to del.icio.us Submit "35 Urologic Surgery" to StumbleUpon Submit "35 Urologic Surgery" to Google Submit "35 Urologic Surgery" to Facebook Submit "35 Urologic Surgery" to Twitter Submit "35 Urologic Surgery" to MySpace

Tags: None Sửa Tags
Chuyên mục
Washington M.of Surgery

Bình luận

# Đăng bình luận qua Facebook