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Urology overview www.medindia.net SRMC – Jan 2000 Dr. SUNIL SHROFF Prof.Urology & Renal Transplantation Sri Ramachandra Medical College & Research Institute.

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Presentation on theme: "Urology overview www.medindia.net SRMC – Jan 2000 Dr. SUNIL SHROFF Prof.Urology & Renal Transplantation Sri Ramachandra Medical College & Research Institute."— Presentation transcript:

1 Urology overview SRMC – Jan 2000 Dr. SUNIL SHROFF Prof.Urology & Renal Transplantation Sri Ramachandra Medical College & Research Institute (Deemed University) Chennai, India AN OVERVIEW OF UROLOGY

2 Urology overview SRMC – Jan 2000 UROLOGY – SUB-SPECIALISATION General Urology Endo-Urology - Upper Urinary Tract Lower Urinary Tract Pediatric Urology Reconstructive Urology / Urodynamics Andrology- Impotence & Infertility Female Urology Renal Transplantation & Access Surgery Uro-Oncology

3 Urology overview SRMC – Jan 2000 IMPORTANT UROLOGY TOPICS Calculus Disease of Urinary Tract Renal Cell Carcinoma & Wilms Tumour Transistional Cell Carcinoma of Bladder Benign Hyperplasia of Prostate Gland Carcinoma of Prostate Gland Testicular Tumours Undescended Testis Urethral Stricture Genito-Urinary Tuberculosis

4 Urology overview SRMC – Jan 2000 Calculus Disease of Urinary Tract

5 Urology overview SRMC – Jan 2000 Renal Cell Carcinoma & Wilms Tumour

6 Urology overview SRMC – Jan 2000 Benign Hyperplasia of Prostate Gland

7 Urology overview SRMC – Jan 2000 Carcinoma of Prostate Gland

8 Urology overview SRMC – Jan 2000 BENIGN TUMOURS OF KIDNEY ADENOMA ANGIOMYOLIPOMA ( RENAL HAMARTOMA) ONCOCYTOMA

9 Urology overview SRMC – Jan 2000 MALIGNANT TUMOURS OF KIDNEY CHILDREN WILMS TUMOUR ADULTS ADENOCARCINOMA OR RCC TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS ( Lining of renal pelvis same as bladder) SQUAMOUS CELL CARCINOMA OF KIDNEY SECONDARIES OR METASTATIC TUMOURS

10 Urology overview SRMC – Jan 2000 POINTS WORTH REMEMBERING 70% OF ASYMPTOMATIC MASS OF KIDNEY ARE BENIGN CYSTS OF NO SIGNIFICANCE ULTRASOUND CAN DISTINGUISH CYSTS FROM SOLID LESIONS ALL BENIGN TUMOURS OF KIDNEY SHOULD BE TREATED AS MALIGNANT UNLESS OTHERWISE PROOVED

11 Urology overview SRMC – Jan 2000 ANGIOMYOLIPOMA BLOOD VESSELS THREE COMPONENTSSMOOTH MUSCLE ADIPOCYTES ASSOCIATED WITH TUBEROUS SCLEROSIS ( Hereditary condition associated with Mental Retardation / Epilepsy / Sebaceous cysts & Hamartomas ) CAN BE BILATERAL OR MULTICENTRIC ABNORMAL BLOOD VESSELS CAN BLEED CAUSING PAIN

12 Urology overview SRMC – Jan 2000 ANGIOMYOLIPOMA DIAGNOSIS USG & CT SCAN ( Fat has a typical Hounsfield number on cat scan ) TREATMENT USUALLY CONSERVATIVE SURGERY - NEPHRON SPARING SURGERY

13 Urology overview SRMC – Jan 2000 RENAL CELL CARCINOMA SYNONYMS GRAWITZ TUMOUR HYPERNEPHROMA ADENOCARCINOMA OF KIDNEY ( Better term )

14 Urology overview SRMC – Jan 2000 RCC - INCIDENCE 3% OF ADULT MALIGNANCIES (USA) SEX RATIO M : F - 2 : 1 Commoner in 5th to 7th decade Von Hippel-Lindau Ds has higher incidence of RCC

15 Urology overview SRMC – Jan 2000 RCC - ETIOLOGY Cell of origin Proximal convoluted tubular cells ( renal adenoma also has same cells of origin) Higher incidence noted in smokers Most consistent chromosomal changes observed Deletion & Translocation of Short arm of Chromosome 3 (3p).

16 Urology overview SRMC – Jan 2000 PATHOLOGY (RCC) General examination Site Usually - Upper or Lower pole Surface Smooth & lobulated Local spread It can penetrate capsule & involve adjoining structures. RCC Can Infiltrate 1.Adrenal 2. Peri-nephric fat 3. Adjoining tissues

17 Urology overview SRMC – Jan 2000 RCC - PATHOLOGY Cut Section : VARIEGATED – SEMICYSTIC & SOLID AREAS - RED OR YELLOW APPEARANCE Microscopic Examination: Two type of cells seen - a). Clear cells with fat & glycogen. b). Pink Mitochondrial Granules in cytoplasm ( Hence variegated appearance )

18 Urology overview SRMC – Jan 2000 RCC - CLINICAL FEATURES - 1 Painless 1. Haematuria (40%) Profuse Paroxysmal 2. Pain (40%) 3. Mass (24%) ( All the three if present called classical triad – Occurs only in 10%. Two of triad in 25% ) 4.Varicocele - 1%

19 Urology overview SRMC – Jan 2000 RCC - CLINICAL FEATURES - 2 OTHER FEATURES CAN BE DIVIDED INTO a). Systemic Effects Stuffer Syndrome Hypercalcemia Erythrocytosis Hypertension Enteropathy b). Non-specific Effects PUO Anaemia Raised ESR Amyloidosis Neuro-myopathy Stuffer Syndrome – RCC with all symptoms & signs of alcoholism & Abnormal LFTs but Normal liver biopsy

20 Urology overview SRMC – Jan 2000 RCC- DIFFERENTIAL DIAGNOSIS 1. Kidney Hydonephrosis Polycystic kidneys 2. Liver:Hepatoma Secondaries 3. AdrenalsNeuroblastoma 4. Retro-peritoneum: Mesenteric cyst Lipoma sarcoma Leiomyosarcoma

21 Urology overview SRMC – Jan 2000 Staging of RCC TNM staging & Hollands staging Hollands Staging Stage 1 - Tumour within Capsule Stage 2 - Tumour involving Perinephric Fat but not through Gerotas Fascia Stage 3 - Tumour involving Regional LN & / or IVC Stage 4 - Tumour involving adjacent organs or distant metastasis

22 Urology overview SRMC – Jan 2000 RCC - Treatment For Stage 1 & 2 Disease RADICAL NEPHRECTOMY Best & most Effective T/t for RCC Excise Kidney en bloc with Gerotas fascia and Adrenal glands and Lymph Nodes ( Thoraco-abdominal approach may be necessary, if renal vein involved and tumour reaches Rt. Ventricle. May need to put patient on By-pass machine)

23 Urology overview SRMC – Jan 2000 RCC - Treatment RCC- Stage 3 or 4 : 1. Chemotherapy: RCC Refractory to most drugs 2. Hormonal Therapy:Provera - 15% response (Bloom) ( Medroxyprogesterone acetate given twice a week) 3. Immunotherapy: Interferons - Side effects can be serious (1st Lymphokine to receive permission for clinical trials) 4. Palliative nephrectomy : Rarely can cause regression of distant mets e.g. canon-ball Sec.

24 Urology overview SRMC – Jan 2000 RCC - PROGNOSIS Poor prognosis: 1.RCC involving renal vein 2.Extension through Gerotas fascia 3. Involvement of regional lymph nodes 4. Mets to distant organs

25 SRMC-Oct99 WILMS TUMOUR

26 Urology overview SRMC – Jan 2000 WILMS TUMOUR Synonymus: Nephroblastoma Incidence: 13 to 20% of malignant tumours of children under 15 yrs. No difference in incidence in different parts of the world. Usually unilateral But can be bilateral Age: Peak at 2 yrs. 75% below 5 yrs. Rare below 6months Pathology: Colour: Grey white Cell of origin: Speculative Embryogenic - Cell rests Blastema cell present Genetic - associated with aniridia/ spina bifida/ GU abnormalities

27 Urology overview SRMC – Jan 2000 WILMS TUMOUR- Pathology Pale Colour Cut Section Solid or semicystic Areas of necrosis Embryonic Blastema Mesenchymal Stroma – Cartilage Microscopic Exam. –or muscle tissue Epithelial Tubules - most distinctive resembles glomeruli & Immature tubules

28 Urology overview SRMC – Jan 2000 WILMS TUMOUR - CLINICAL FEATURES 1. Mass in abdomen - May grow to a huge mass. Tumour grows within capsule and pushes kidney to one side. Hence shape of tumour not reniform 2. Pyrexia - PUO in 50% of patients. 3. Haematuria - Poor prognosis. Usually due to Encapsulated tumour infiltrating through capsule.

29 Urology overview SRMC – Jan 2000 WILMS TUMOUR - TREATMENT 1. Radical Nephrectomy and post-op radiotherapy. 2. Bilateral Wilms - Role of Nephron conserving surgery. Prognosis: If presentation under 1 yr prognosis good

30 Urology overview SRMC – Jan 2000 BENIGN PROSTATE HYPERTROPHY (BPH) BPH is the MOST COMMON benign tumour in men Men surviving over 50 years and who live up to 80 years stand 20 to 30% chance of undergoing surgery for BPH

31 Urology overview SRMC – Jan 2000 BPH - PATHOLOGY McNeal (1990) - divided prostate in Four distinct zones: 1. Anterior Zone 2. Central Zone 3. Peripheral Zone 4. Transition Zone - ( BPH ) this zone coincides with Lateral lobes of prostate

32 Urology overview SRMC – Jan 2000 BPH - Microscopic Examination BPH characterised by Nodules BPH characterised by Nodules Both Epithelial & Stromal elements involved to varying degree Both Epithelial & Stromal elements involved to varying degree Based on above Five types of Histopathology described: Based on above Five types of Histopathology described: 1. Stromal 2. Fibromuscular 3. Muscular 4. Fibroadenomatous 5. FIBROMYOADENOMATOUS - the most common type.

33 Urology overview SRMC – Jan 2000 DOG they say is a mans best friend, certainly this is true when it comes to development of BPH, in mammals - only in Dog & man does prostate hyperplasia takes place spontaneously !! But man is not dogs best friend as all the experiments are done on dogs prostate !!! Prostate and The Story of Dog & His Master

34 Urology overview SRMC – Jan 2000 BPH - Symptoms With Progressively obstructive gland constellation of symptoms called - PROSTATISM develops. Irritative SymptomsObstructive Symptoms FrequencyHesitancy Urgency Poor stream - Force/Calibre NocturiaPost-Void Dribbling Urgency IncontinenceFeeling of Incomplete Voiding Straining to pass urine Urinary Retention

35 Urology overview SRMC – Jan 2000 Obstructed muscle Hyperplasia & Hypertrophy Deposition of collagen fibres Lead to a loss of Bladder Compliance. This can also lead to loss of normal control over the Reflex detrusor response causing detrusor decompensation and detrusor Instability Detrusor Instability can be Confirmed by Urodynamics study - this study measures Detrusor pressure during Filling phase & Voiding Phase of bladder Detrusor response to Obstruction

36 Urology overview SRMC – Jan 2000 BPH- AETIOLOGY Remember AGE & TESTIS With age, Sensitivity of Prostatic glands to circulating androgens increases With age, there is a decrease in androgens ( Testosterone & Dihydrotestosterone) & this induces the prostate to grow ( ANDROGENS play a major role in development of BPH )

37 Urology overview SRMC – Jan 2000 BPH- SIGNS 1. Per Rectal examination – Size of the gland – in mls/ gms consistency – Firm / Hard shape - Regular / Irregular (BPH causes smooth, firm & elastic enlargement of prostate. Obstructive Symptoms No relation to Size of gland ) 2. Signs of CRF -Look for signs of anaemia, Evidence of weight loss, Cardiomegaly or Pulmonary oedema

38 Urology overview SRMC – Jan 2000 DIFFERENTIAL DIAGNOSIS 1. Stricture of Urethra 2. Carcinoma of Prostate 3. Neurogenic Bladder 4. Vesical Calculus 5. Urinary tract Infection

39 Urology overview SRMC – Jan 2000 BPH -Investigations 1. Hb 2. Electrolytes / BUN/ Creatinine 3. Prostate Specific Antigen / Acid Phosphatase 3. Flow Rate : To measure the speed of flow of the urine depicted usually as a graph 4.MSU / CSU- For culture & sensitivity of urine 5. KUB plain x-ray of the abdomen 6.US of abdomen – Besides KUB also ask for Post-void residual. Normally there should be nil or minimum residual i.e. less than 50 mls after voiding ( Presence of residual means incomplete voiding

40 SRMC-Oct99 Hippocrates & Galen declared that surgical opening of the Bladder was usually fatal & should be avoided!!

41 Urology overview SRMC – Jan 2000 Open Prostatectomy Wrong term It should be called adenomyomectomy, as whole prostate not removed, only adenoma removed Trans-vesical (Freyers) Retro-pubic (Millins) Perineal (Youngs) ( For any prostate surgery always warn patient about retro- grade ejaculation and always take consent for the same )

42 Urology overview SRMC – Jan 2000 Treatment Modalities for BPH 1. Trans-urethral resection of prostate 2. Trans-Urethral Incision of the Prostate 3. Laser Prostatectomy - Nd:YAG laser 4. Microwave Hyperthermia 5. Cryo-surgery of prostate 6. Ultrasound Ablation 7. Balloon Dilatation of the Prostate Drugs: (BPH) – Alpha- blockers - Prazosin / Terazosin 5-alpha reductase - Finasteride

43 Urology overview SRMC – Jan 2000 TUR Syndrome Absorbed Glycine Free Ammonia (Neurotoxin). Absorbed Glycine Cross the blood- brain barrier &act as inhibitory transmitter W ater can be used but absorption causes hemolysis of RBCs) Syndrome characterised by dramatic Reversible Neurological symptoms which are reversible: Mental confusion Shortness of breath Bradycardia Cyanosis Increase or decrease of BP Oliiguria Coma

44 Urology overview SRMC – Jan 2000 Complications of Surgery 1. Haemorrhage : 2. TUR SYNDROME 3. Incontinence 4. Sexual Dysfunction – Retrograde ejaculation ( 50%) Erectile Impotence (5 to 10% ) 5. Urethral Stricture - 1 to 12% 6. Re-operation & Death


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