What Is Urology

1. What Is Urology? A surgical field: & A medical field: Urinary Tract Male Genital Tract

2. A Urologist: �a friendly, funny, and happy surgeon" Why so happy? A discrete field True �experts� Rapidly evolving Efficacious treatments Better surgical �lifestyle� ��general surgeons are jealous� (GH Jordan)

3. Urology Now: Subspecialties Laparoscopy Stones/Endourology Oncology Incontinence/Voiding Reconstructive Surgery Transplant Sexual Dysfunction Infertility Pediatric

4. Rotation Goals Goal: A general overview of urology: Preceptor based rotation Two: 1 week preceptorships Try to cover all bases Obtain schedule from preceptor Call preceptor�s office before rotation starts Questions or concerns? Please communicate Let me know if something is wrong

5. Weekly Events Obtain weekly schedule from preceptor Teaching Rounds (with residents) Thurs AM (8am-11am) at Alberta Urology Institute Grand Rounds Friday AM (7am-8am) at Alberta Urology Institute Interesting Case Rounds Tues AM (7am-8am) at AUI If convenient (in office or at RAH that day) Alberta Urology Institute #400 Hys Centre Labcoats please

6. Genitourinary Imaging: Case Concepts Keith Rourke Division of Urology

7. Case 1: �Flank Pain� 50 year old female Left flank pain (intermittent) Other questions?

8. Physical Exam: T 37.3 PR 108 RR 20 BP 130/88 Abdomen: Normal sounds, contour Soft, no mass, no organomegaly Mild left CVA tenderness

9. Further Testing Laboratory: WBC 10.6, Cr 80 U/A: 50 RBC/hpf Plain film (KUB) normal ? Radiologic tests

10. Intravenous Pyelogram (IVP) Scout film Intravenous contrast Serial xrays Nephrogram phase (1min) Pyelogram phase (5 min) Delayed views (ureter) Post void Tomograms

11. IVP: Left kidney � Case patient

12. Filling Defect: Differential Diagnosis Stone Tumour (TCC) Blood clot Fungal debris (�fungus ball�) Vascular impression Sloughed papilla ? Next test

13. Non-contrast CT Abdomen

14. Renal Colic Sudden, intense flank, groin or genital pain Associated nausea & vomiting Restlessness, �uncomfortable in any position� >75% microscopic hematuria Similar presentation: Aortic aneurysm Acute bowel obstruction Diverticulitis

15. Renal Colic: Diagnosis KUB: 80-90% of stones are radio-opaque Phleboliths IVP: Demonstrates stone location & degree of obstruction Time consuming & contrast risk CT (Non-contrast) Quick, sensitive Concurrent intra-abdominal pathology

16. IVP: Ureteral Calculus

17. IVP Complications: Contrast reaction 5-8% incidence (<1% severe) Mild Flushing, nausea, urticaria Moderate Bronchospasm, angioedema Severe Hypotension, arrythmia, pulmonary edema Treatment: Diagnosis, IV fluids, antihistamine, epinephrine Prevention: Premedication: Benadryl, corticosteroid

18. Non-contrast CT: Ureteral Calculus Hydronephrosis, perinephric stranding

19. Non-contrast CT:Ureteral Calculus Dilated ureter above stone

20. Ureteral Calculus:Non-contrast CT Stone visualization & location All stones are �radio-opaque� on CT �Tissue ring� sign

21. Renal Colic: Management IV fluids Parenteral analgesia Strain urine Admission criteria Poor analgesia Unable to tolerate oral hydration Infection & obstruction Solitary kidney/renal failure NOT hematuria, complete obstruction or stone size

22. Renal Colic: Treatment Spontaneous stone passage depends on: Location: Proximal vs. distal Size: ~80% of stones <5mm will pass Time since onset: Most stones pass at ~2-3weeks Extracorporal shock wave lithotripsy (ESWL) Upper ureter or renal stones <2cm Ureteroscopic Ureteral stones or ESWL failures Percutaneous Large >2cm renal stones

23. Case 2: �Gross Hematuria� 68 year old male Gross hematuria

24. Case 2: Examination & Lab PR 80 RR18 BP 155/80 T 37.2 Abdomen: No mass, tenderness or organomegaly GU: Normal penis, testes & spermatic cord Urine cytology: Few atypical cells ? Radiologic Investigations

25. Renal Ultrasound (left) Normal study Note parenchyma, renal sinus

26. Renal Ultrasound (right) Low level echogenic focus ? Differential diagnosis

27. Renal Ultrasound Quick, safe, inexpensive Suitable for detecting: Hydronephrosis Renal masses Renal cysts (excellent) Renal stones (but not ureteric) Initial study (upper tract) for hematuria ? Next test

28. IVP: Evaluation of collecting system

29. CT Abdomen: No contrast

30. CT Abdomen: After Contrast Any further �radiologic� testing ?

31. Retrograde Pyelogram Standard for imaging renal collecting system Cystoscopy performed Ureteral orifice cannulated Contrast injection �Selective cytology � Brush biopsy

32. Concurrent Bladder Finding

33. Hematuria Microscopic hematuria >3 RBC/hpf is significant Evaluate over age 40 Gross hematuria Evaluate at any age Causes Tumour (renal or bladder) Stones Infection Trauma BPH Medical

34. Evaluation of Hematuria Upper tract evaluation Ultrasound IVP CT ? MRI (second line) Lower tract evaluation Cystoscopy is the gold standard Other studies: Cytology, U/A, RGPyelogram

35. Transitional Cell Carcinoma (Bladder) Most common cause of gross hematuria over age 40 Male: Female (3:1) Most common bladder tumour (>85% tumours) Risk factors Smoking Dyes (aniline, naphthylamine, benzidine) Pelvic irradiation Cyclophosphamide ? Dehydration

36. TCC Bladder (cont�d) Urine cytology is insensitive but specific Radiologic investigations have a high false negative rate Cystoscopic (�visual�) diagnosis Staging (TNM) Ta: Papillary tumour invading only mucosa Tis: Carcinoma in situ T1: Invading lamina propria T2: Muscle invasion T3: Fat invasion (extramural) T4: Invading adjact organs

37. TCC Bladder (Treatment) Dependent on stage Ta Transurethral resection (TURBT) T1 TUR + Intravesical therapy (BCG) T2, T3 Radical cystectomy & urinary diversion T4 Chemo, RT � Radical cystectomy

38. TCC Bladder: Followup Prone to recurrence Cystoscopic surveillence Every 3months x 2years Then q6 months x 2 years Then annually

39. TCC: Upper tract (Renal Pelvis) Uncommon, 6% of all renal cancers 50% will develop TCC in bladder Evaluate concurrently 2-4% of TCC bladder patients have upper tract Similar RF�s to TCC bladder & Balkan nephropathy Treatment Radical nephroureterectomy (excise entire ureter)

40. Case 3: �Even More Hematuria� 62 year old male Gross hematuria Right flank discomfort On history: No trauma No urolithiasis PMH: Hypertension

41. Case 3: Cont�d On Exam: Abd: RUQ pain, No discrete mass, No organomegaly GU: Right varicocele, No hernia DRE: Benign prostate, Mildly enlarged Lab: Cr 98 , N CBC U/A: >50 RBC/HPF Flex Cystoscopy Normal

42. IVP: Not very helpful Possible Mass effect inferiorly (circle)

43. Renal Ultrasound Mixed echogenic mass (right kidney)

44. Differential Diagnosis: Renal Mass Renal Cell Carcinoma Oncocytoma Angiomyolipoma Lymphoma Upper tract TCC Metastatic lesion Other: Sarcoma, Squamous cell carcinoma

45. CT Abdomen (with contrast) Solid renal mass Contrast enhancement Areas of central necrosis Assymmetric margins Dilated renal vein ? Most likely diagnosis ? Further radiologic evalation

46. MRI: Case 3 Heterogenous renal mass (circle)

47. Case 3: MRI Right renal vein/IVC thrombus Renal cell carcinoma with extension into renal vein (tumour thrombus)

48. Renal Cell Carcinoma: Epidemiology 3% of all adult malignancies 90% of malignant renal tumours Males:females = 2:1 Arise from proximal convoluted tubule Risk factors: Smoking (mild) von Hippel Lindau (VHL) syndrome �Bad luck�

49. Renal Cell Carcinoma: Presentation Age 40-60 ~60% are incidentally discovered (ultrasound, etc) Hematuria 15% have �classic triad� of flank pain, abdominal mass, & hematuria Paraneoplastic syndromes Hypercalcemia Increased LFT�s (�Staufer sydrome�) ACTH Hypertension, etc.

50. Renal Cell Carcinoma: Diagnosis Based on radiographic studies Incidental ultrasound CT is the method of choice MRI Assess large tumours/local extension Assess for renal vein/caval extension (thrombus)

51. RCC: Treatment Localized disease: Nephrectomy (is the only cure) Radical vs. Partial (small or bilateral tumours) Radiotherapy not beneficial Chemotherapy ineffective Metastases: Palliative radiotherapy (bony lesions) Immunotherapy (Interferon, IL-2)

52. Other Renal Masses: Oncocytoma <3% renal tumours Benign lesion Indistinguishable from RCC radiographically �Pathologic diagnosis� Treatment: Nephrectomy

53. Renal Mass: Angiomyolipoma Composed of blood vessels, fat & muscle Benign but prone to hemorrhage (>4cm) Associated with tuberous sclerosis CT is diagnostic Fat within tumour

54. Case 4: �An incidental finding� 62 year old female Sudden onset of hypertension Concurrent �panic attacks� & constipation Referred to internist BP 160/100 CT abdomen (Rule/out �renal hypertension�)

55. CT Abdomen: With IV contrast

56. Adrenal Mass: Differential Diagnosis Adrenal adenoma (<5cm) Adrenocortical carcinoma (>5cm) Pheochromocytoma Metastases Myelolipoma ? Further testing

57. Metabolic Evaluation: Adrenal Mass Serum electrolytes, creatinine 24 hour urine: Catecholamines & metanephrines (all patients) Cortisol (if �Cushing�-oid) Aldosterone (if hypertensive, hypokalemic) ? Next test

58. MRI: T1 coronal image Medium signal adrenal mass

59. MRI: T2 axial image �Light bulb� appearance diagnostic of pheochromocytoma

60. Adrenal Mass Incidental finding in ~1% of all abdominal xrays (ultrasound, CT) Must exclude pheochromocytoma (metabolic evaluation) Adenomas are generally small (<5cm) May be endocrinologically active Adrenocortical carcinoma Lesions >5cm considered malignant (adrenalectomy) MRI is in an excellent diagnostic modality for adrenal masses

61. Case 5: �My Sack Hurts� 22 year old male Left scrotal pain x 5 hours On history:

62. Case 5: On Examination Vitals: PR 104 RR22 BP 132/82 T 37.9 Abdomen: Soft, non-tender, no mass, no megaly GU: Normal circumcised penis, no discharge Swollen, markedly tender left testes/epididymis (no transillumination) Normal right testes No hernia

63. Case 5: Lab WBC 11.2 Normal BUN,Cr, E�lytes U/A: 3-5 WBC/HPF ? Differential Diagnosis

64. Acute Scrotum: Differential Diagnosis Torsion (of spermatic cord) Epididymitis +/- Orchitis Torsion of testicular appendage ? Tumour ? Varicocele Hernia ? Radiographic investigations

65. Scrotal Ultrasound (with Doppler):Right Testicle Normal arterial waveform

66. Scrotal Ultrasound (with Doppler):Left Testicle Absent arterial flow

67. Testicular Torsion Urologic emergency Sudden onset, incidental trauma, prior episodes, visceral stimulation (nausea) Patient age 12-20 in 65% of cases Requires prompt surgical intervention: (reduction of torsion & bilateral fixation) 97% testicular salvage if <6 hours 55-85% if 6-12 hours <10% if >24 hours �Bell clapper deformity� (congenital narrowing of cord)

68. Testicular Torsion Immediate exploration if suspicious Imaging if diagnosis uncertain Duplex ultrasound: ~82-100% sensitivity Operator dependent Heterogenous testicle with absent flow Nuclear testicular scan: Seldom performed Time consuming Was once the preferred radiographic test

69. Epididymitis Most common cause of acute scrotum after adolescence Pyuria (50%), Fever (30%) Increased flow to epididymis/testes Cause: Age <40: Chlamydia Age>40: E.Coli Treatment: IM Ceftriaxone/PO Azithromycin 10 days fluoroquinolone NSAID�s

70. Torsion of Testicular Appendage Torsion of appendix testes or appendix epididymis �Blue dot� sign (seen on scrotum) More focal pain (upper hemiscrotum) Often difficult to distinguish from other causes Treatment: Conservative Pain relief

71. Other causes: Acute Scrotum Testicular Tumour: Usually painless unless acute hemorrhage occurs Hernia (incarcerated): Arising from �above the scrotum� Varicocele (scrotal varices): Retrograde flow into testicular veins Infrequent cause of pain unless acute thrombosis occurs May cause infertility

73. Varicocele

74. Oncocytoma: Angiogram Classic �spoke wheel� angiographic appearance of an oncocytoma Not diagnostic