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AN OVERVIEW OF UROLOGY Dr. SUNIL SHROFF Prof.Urology & Renal Transplantation Sri Ramachandra Medical College & Research Institute (Deemed University)

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Presentation on theme: "AN OVERVIEW OF UROLOGY Dr. SUNIL SHROFF Prof.Urology & Renal Transplantation Sri Ramachandra Medical College & Research Institute (Deemed University)"— Presentation transcript:

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

2 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 SRMC – Jan’ 2000

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

4 Calculus Disease of Urinary Tract
SRMC – Jan’ 2000

5 Renal Cell Carcinoma & Wilm’s Tumour
SRMC – Jan’ 2000

6 Benign Hyperplasia of Prostate Gland
SRMC – Jan’ 2000

7 Carcinoma of Prostate Gland
SRMC – Jan’ 2000

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

9 MALIGNANT TUMOURS OF KIDNEY
CHILDREN WILM’S 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 SRMC – Jan’ 2000

10 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 SRMC – Jan’ 2000

11 ANGIOMYOLIPOMA BLOOD VESSELS THREE COMPONENTS SMOOTH 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   SRMC – Jan’ 2000

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

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

14 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 SRMC – Jan’ 2000

15 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). SRMC – Jan’ 2000

16 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 SRMC – Jan’ 2000

17 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 ) SRMC – Jan’ 2000

18 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% SRMC – Jan’ 2000

19 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 LFT’s but Normal liver biopsy SRMC – Jan’ 2000

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

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

22 RCC - Treatment RADICAL NEPHRECTOMY For Stage 1 & 2 Disease
Best & most Effective T/t for RCC Excise Kidney en bloc with Gerota’s 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) SRMC – Jan’ 2000

23 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. SRMC – Jan’ 2000

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

25 WILM’S TUMOUR  

26 WILM’S 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 SRMC – Jan’ 2000

27 WILM’S 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 SRMC – Jan’ 2000

28 WILM’S 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. SRMC – Jan’ 2000

29 WILM’S TUMOUR - TREATMENT
1. Radical Nephrectomy and post-op radiotherapy. 2. Bilateral Wilm’s - Role of Nephron conserving surgery. Prognosis: If presentation under 1 yr prognosis good SRMC – Jan’ 2000

30 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 SRMC – Jan’ 2000

31 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 SRMC – Jan’ 2000

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

33 Prostate and The Story of Dog & His Master
DOG they say is a man’s 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 dog’s best friend as all the experiments are done on dog’s prostate !!! SRMC – Jan’ 2000

34 BPH - Symptoms Irritative Symptoms Obstructive Symptoms
With Progressively obstructive gland constellation of symptoms called - “PROSTATISM” develops. Irritative Symptoms Obstructive Symptoms Frequency Hesitancy Urgency Poor stream - Force/Calibre Nocturia Post-Void Dribbling Urgency Incontinence Feeling of Incomplete Voiding Straining to pass urine Urinary Retention SRMC – Jan’ 2000

35 Detrusor response to Obstruction
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 SRMC – Jan’ 2000

36 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 ) SRMC – Jan’ 2000

37 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 SRMC – Jan’ 2000

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

39 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 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 SRMC – Jan’ 2000

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

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

42 Treatment Modalities for BPH
Trans-urethral resection of prostate Trans-Urethral Incision of the Prostate Laser Prostatectomy - Nd:YAG laser Microwave Hyperthermia Cryo-surgery of prostate Ultrasound Ablation Balloon Dilatation of the Prostate 8. Drugs: (BPH) – Alpha- blockers - Prazosin / Terazosin 5-alpha reductase - Finasteride SRMC – Jan’ 2000

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

44 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 SRMC – Jan’ 2000


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