pitfalls of urology for

Pitfalls of Urology for Undergraduate studies at Taylor University - PowerPoint PPT Presentation

David A. Anderson, MD Born in Sioux City, Iowa Pitfalls of Urology for Undergraduate studies at Taylor University Medical School at University of Iowa College of the Gatekeeper Medicine Internship and Residency at University of

  1. David A. Anderson, MD ■ Born in Sioux City, Iowa Pitfalls of Urology for ■ Undergraduate studies at Taylor University ■ Medical School at University of Iowa College of the Gatekeeper Medicine ■ Internship and Residency at University of Iowa Hospitals and Clinics What are they and how to avoid them ■ Joined Ferrell Duncan Clinic, Springfield MO in 2005 David A. Anderson, MD ■ Interests include Robotics, Minimally invasive surgery Ferrell Duncan Clinic, 2016 and treatments of Incontinence

  2. Objectives Anatomic Approach to Urologic Pathology ■ Bladder ■ Hopefully you will be able to… ■ Kidney ■ Renal Cell/Urothelial Cell ■ Urothelial Malignancies ■ Identify common clinical urologic presentations Tumors ■ Cystitis ■ Establish a quick differential diagnosis ■ Nephrolithiasis ■ Bladder Stones ■ Develop a diagnostic plan and execute treatment or ■ Congenital obstructions/ ■ Interstitial Cystitis refferal Hydronephrosis ■ Asymptomatic Bacteruria ■ Pyelonephritis ■ Hopefully you will not… ■ Incontinence ■ Renal Cyst ■ Stress ■ Be offended by my sense of humor ■ Urge ■ Be grossed out by pictures of scrotums ■ Overflow ■ Fall asleep out of complete boredom Clinical Approach to common Urologic Anatomic Approach to Urologic Pathology pathology ■ Prostate ■ Testicle ■ Hematuria ■ Definition, workup, common findings ■ Prostate Cancer ■ Testicular Cancer ■ Testicular Torsion ■ Elevated PSA ■ BPH ■ Epididymitis/Orchitis ■ Current recommendations, workup and causes ■ Prostatitis ■ Orchalgia ■ Flank Pain ■ Penis ■ Spermatocele ■ Differential dx, work up, referral ■ Penile Cancer ■ Hydrocele ■ Recurrent UTI’s ■ Penile Trauma ■ Varicocele ■ Causes, work up, treatment options ■ Phimosis/Paraphimosis ■ Undescended Testicle ■ Pelvic Pain ■ Differential dx, work up and treatment options

  3. Kidney Kidney ■ Renal Cell Carcinoma ■ About 36,000 new cases each year in the U.S. ■ Results in about 12,500 deaths per year ■ Peak incidence is in 50-70 year olds ■ More common in men by 2:1 ■ Smoking accounts for 20-30% of cases ■ Obesity is a risk factor ■ Genetic factors identified for a minority of cases Kidney Kidney ■ Signs and Symptoms ■ Renal Cell Cancer Treatment ■ Hematuria (40-60%) ■ Surgery in cases without distant spread ■ Flank pain (30-40%) ■ Laparoscopic vs. Open Radical Nephrectomy ■ Weight loss (33%) ■ Robotic vs. Open Partial nephrectomy ( Tumors <4 cm) ■ Anemia (33%) ■ Radiation therapy ■ Palpable mass (25%) ■ Not very effective, almost no role ■ Chemotherapy ■ Diagnostic Studies ■ Not very effective ■ CT Ab/Pelvis w/ contrast ■ Immunotherapy ■ MRI ■ Not very effective, shown to add 2-4 months avg life expectancy ■ U/S

  4. Kidney Kidney ■ Nephrolithiasis ■ Kidney stones ■ May detach and lodge in ■ Requires “supersaturation” of urine with an insoluble the ureter material such as calcium oxalate or cysteine ■ Acute pain syndrome ■ More likely if... ■ Hydronephrosis due to complete occlusion ■ Urine flow is low (water conservation) ■ May grow to large to pass ■ Mineral (esp. calcium salts) production is high & fill renal pelvis ■ Urine mineral concentration is high ■ “Staghorn calculi” ■ Idiopathic (hereditary) hypercalciuria ■ Deficit of mineral dissolvers such as Citrate Kidney Kidney ■ Clinical Presentation of Stones ■ Treatment options for Stones ■ PAIN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ■ Ureteroscopy ■ Flank to lower quadrant as the stone passes ■ Using a scope to extract stone either with a basket or with a laser ■ Colicky in nature, usually 12/10 pain ■ Only risk in ureteral injury ■ Pain that narcotics wont help ■ Lithotripsy ■ Nausea and Vomiting ■ Very effective (95%) with only sedation ■ Hematuria ■ May cause renal damage ■ Urgency and frequency if stone is distal ■ Percutaneous Nephrolithotripsy ■ Testicular pain, pelvic pain ■ Directly into kidney, reserved for large stones

  5. Kidney ■ Acute Pyelonephritis ■ Infection of upper urinary tract associated with fever, flank pain, pyuria, possible sepsis ■ Requires antibiotic therapy usually requires hospitalization and may need surgical intervention ■ Relieve obstruction with either stent or removal of stone ■ Xanthogranulomatous pyelonephritis is a chronic form where nephrectomy is required ■ Antibiotic treatment usually requires flouroquinolones, cephalosporins, or aminoglycosides (gent) Bladder Bladder ■ Urothelial Carcinoma (Transistional Cell Ca) ■ 60,000 new cases per year in the U.S. ■ 12,700 deaths per year ■ Males outnumber women by nearly 3:1 ■ 60-75% of cases are due to smoking or exposure to industrial dyes or solvents ■ Squamous Cell Carcinoma ■ Much less common ■ Usually found in patients who are chronically catheterized

  6. Bladder Bladder ■ Signs and Symptoms ■ Diagnosis ■ Hematuria on UA leads to ■ Hematuria either IVP or CT Ab/ ■ Often gross but may be microscopic Pelvis and Cystoscopy ■ Presenting symptom in ■ Transurethral Resection 85-90% may be curative depending ■ Irritative voiding on stage symptoms ■ Most (50-80%) bladder cancers will be superficial at diagnosis: ■ Pain, masses with ■ CIS, Ta, T1 advanced disease ■ Advanced disease: Cystectomy vs Chemo/ XRT Bladder Bladder ■ UTI ■ UTI Signs and Symptoms ■ “ Irritative voiding symptoms ” ■ Simple/Uncomplicated UTI ■ Urinary frequency, urgency, pain (dysuria) ■ Cystitis in female, no other factors ■ Hematuria (may be microscopic) ■ Lower urinary tract involved, no fever, local symptoms ■ Fever: most common in children ■ Complicated UTI ■ Pyelonephritis ■ Cystitis in Male, pyelonephritis, catheterized patients, immunocompromised patients, or other factors ■ Fever, nausea, vomiting, flank pain ■ Upper tract involvement, instrumentation, catheters, ■ UA neurogenic bladders ■ Presence of WBC and Bacteria on UA, Nitrite +, Leukocyte esterase +, CULTURE

  7. Bladder Bladder ■ UTI Diagnosis ■ Asymptomatic Bacteruria ■ UA ■ Common in the elderly ■ + WBC, +/- RBC ■ General recommendation is to not treat unless ■ +Nitrite patient becomes symptomatic ■ +Leukocyte esterase ■ + Bacteria ■ Fever, constitutional symptoms, dysuria, irritative ■ Culture symptoms ■ >100,000 CFU/HPF of ■ Also common in pregnancy bacteria ■ Usually treated to avoid pyelonephritis ■ Dipstick + Urine is ■ Also associated with premature labor correct 20% of the time!! Bladder Bladder ■ Urinary Incontinence ■ Treatment ■ Uncomplicated UTI ■ Stress Incontinence ■ 3-5 days of TMP/SMZ ■ Intrinsic urethral sphincter deficiency from age, ■ Hydration, AZO hysterectomy and multiple vaginal deliveries ■ Complicated UTI ■ Urge incontinence ■ 10-14 days of TMP/SMZ or Flouroquinolone ■ Overactivity of M2 and M3 receptors in the bladder ■ May need cephalosporin or augmentin causing an increase in contraction of detrusor ■ Change catheter or stent ■ Can be cause by detrusor dysfunction from MS, diabetes or ■ Pyelonephritis sacral nerve injury ■ 14-21 days of flouroquinolone ■ Most commonly idiopathic but must rule out infection and ■ May need IV abx w/ or w/o hospitalization intravesical lesions

  8. Bladder ■ Urge incontinence treatments ■ Behavior modification (“bladder training”) ■ Void every 1-2 hours ■ Gradually lengthen time between voids ■ Eliminate irritants like smoking, caffeine, and acidic foods ■ Anticholinergic (antimuscarinic) drugs ■ Oxybutynin (Ditropan) Detrol LA, Vesicare, Enablex, Toviaz, Gelnique, Sanctura ■ Botox Injections ■ Interstim Therapy Prostate Prostate ■ Prostate Cancer ■ Signs and Symptoms ■ Early stages almost none ■ About 230,000 new cases per year in the U.S. ■ PSA elevation ■ 1 in 7 lifetime risk of “clinical” disease ■ Abnormal rectal exam ■ Results in about 30,000 annual deaths ■ Late stages can have bone pain and lower urinary tract ■ Second leading cause of male cancer deaths obstruction ■ Lung CA is still #1 ■ Diagnosis ■ Compares to breast cancer: ■ DRE and PSA ■ 216,000 cases/year ■ TRUS Bx ■ 40,000 deaths/year ■ CT and Bone Scan to eval for metastasis ■ 1 in 8 lifetime risk

  9. Prostate Prostate ■ AUA guidelines ■ USPTF ■ PSA still indicated for men age 55-69 ■ Routine PSA screening is not indicated for any age group (Group D recommendation) ■ Should have annual DRE and PSA but some may elect to go every other year ■ Routine PSA screening did not show to increase either disease free survival or overall survival ■ No benefit to screening men <54 or >70 ■ Report sighted the risks of biopsy, ED, and ■ IF elevated above 4.0 or have increase of 0.75 or incontinence outweighed the benefits. more in 6 months, should have discussion of biopsy ■ Showed no changes in mortality in the screened groups Prostate Prostate ■ Prostate Cancer Treatment options ■ Benign Prostatic Hyperplasia ■ Watchful waiting ■ Increases in prevalence with age ■ Limited to men >75 or with <10 life expectancy ■ 50% by age 60 ■ Hormone Therapy ■ 80% by age 80 ■ About half with prostatic hypertrophy are symptomatic ■ Limited to stage T3 or T4 or PSA >50, suspect metastasis ■ Etiology: ■ Radiation Therapy ■ Multifactorial ■ Brachytherapy or XRT, T1 or T2, 80% long term survival ■ Surgical Management ■ Incompletely understood ■ Does require dihydrotestosterone and aging ■ Open or Robotic Prostatectomy ■ Cryo surgery or HIFU

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