Smith and Tanagho's General Urology, Eighteenth Edition

Höfundar: Jack W. McAninch; Tom F. Lue (Útgáfa: 18)
Smith and Tanagho's General Urology, Eighteenth Edition

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The definitive guide to understanding, diagnosing, and treating urologic disorders – completely updated with the latest clinical developments A Doody's Core Title for 2024! Smith & Tanagho’s General Urology, 18th edition offers a complete overview of the diagnosis and treatment of the diseases and disorders managed by urologic surgeons. This trusted classic delivers a clear, concise presentation of the etiology, pathogenesis, clinical findings, differential diagnosis, and medical and surgical treatment of all major urologic conditions.

The well-organized, user-friendly design makes relevant clinical information and management guidelines easy to find and simple to implement. Features: High-yield descriptions of the latest diagnostic modalities and management protocols More than 1,600 illustrations and figures, including CT scans, radionuclide imaging scans, and x-rays NEW chapter on robotic surgery in urology Extensively updated chapters on chemotherapy of urologic tumors, neoplasms of the prostate, and vascular interventional radiology Ideal for residents and medical students who require a concise and comprehensive reference Great for board preparation.

Nánar um bókina

Útgefandi
McGraw-Hill Professional
ISBN
9780071632607
Print ISBN
9780071624978
Format
ePub
Útgáfa
18
Höfundar
Jack W. McAninch; Tom F. Lue
Tungumál
English
Útgefið
2012-08-22
Prent takmörkun á líftíma
10

Kaflar

  • Front Matter
  • Dedication
  • Contents
  • Contributors
  • Preface
  • 1 Anatomy of the Genitourinary Tract
  • ADRENALS
  • Gross Appearance
  • A. Anatomy
  • B. Relations
  • Histology
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Lymphatics
  • KIDNEYS
  • Gross Appearance
  • A. Anatomy
  • Figure 1-1. Anatomy of the male genitourinary tract. The upper and midtracts have urologic function only. The lower tract has both genital and urinary functions.
  • Figure 1-2. Relations of kidney, ureters, and bladder (anterior aspect).
  • B. Relations
  • Histology
  • A. Nephron
  • Figure 1-3. Relations of kidneys (posterior aspect). The dashed lines represent the outline of the kidneys where they are obscured by overlying structures.
  • B. Supporting Tissue
  • Blood Supply (Figures 1-2, 1-4, and 1-5)
  • A. Arterial
  • B. Venous
  • Nerve Supply
  • Lymphatics
  • Figure 1-4. Anatomy and histology of the kidney and ureter. Upper left: Diagram of the nephron and its blood supply. (Courtesy of Merck, Sharp, Dohme: Seminar. 1947;9[3].) Upper right: Cast of the pelvic caliceal system and the arterial supply of the kidney. Middle: Renal calices, pelvis, and ureter (posterior aspect). Lower left: Histology of the ureter. The smooth-muscle bundles are arranged in both a spiral and a longitudinal manner. Lower right: Longitudinal section of kidney showing calices, pelvis, ureter, and renal blood supply (posterior aspect).
  • Figure 1-5. A: The posterior branch of the renal artery and its distribution to the central segment of the posterior surface of the kidney. B: Branches of the anterior division of the renal artery supplying the entire anterior surface of the kidney as well as the upper and lower poles at both surfaces. The segmental branches lead to interlobar, arcuate, and interlobular arteries. C: The lateral convex margin of the kidney. Brödel's line, which is 1 cm from the convex margin, is the bloodless plane demarcated by the distribution of the posterior branch of the renal artery.
  • CALICES, RENAL PELVIS, AND URETER
  • Gross Appearance
  • A. Anatomy
  • B. Relations
  • Histology (Figure 1-4)
  • Figure 1-6. Anatomy and relations of the ureters, bladder, prostate, seminal vesicles, and vasa deferentia (anterior view).
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Lymphatics
  • BLADDER
  • Gross Appearance
  • A. Anatomy
  • B. Relations
  • Histology (Figure 1-10)
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Nerve Supply
  • Lymphatics
  • PROSTATE GLAND
  • Gross Appearance
  • A. Anatomy
  • Figure 1-7. A: Anatomic relationship of the bladder, prostate, prostatomembranous urethra, and root of the penis. B: Histology of the testis. Seminiferous tubules lined by supporting basement membrane for the Sertoli and spermatogenic cells. The latter are in various stages of development. C: Cross sections of the testis and epididymis. (A and C are reproduced, with permission, from Tanagho EA: Anatomy of the lower urinary tract. In: Walsh PC et al [eds] Campbell's Urology, 6th edn., Vol. 1. Saunders, Philadelphia, PA, 1992.)
  • Figure 1-8. Top: Relations of the bladder, prostate, seminal vesicles, penis, urethra, and scrotal contents. Lower left: Transverse section through the penis. The paired upper structures are the corpora cavernosa. The single lower body surrounding the urethra is the corpus spongiosum. Lower right: Fascial planes of the lower genitourinary tract. (After Wesson.) (Tanagho EA: Anatomy of the lower urinary tract. In: Walch PC et al [eds] Campbell's Urology. 6th edn., Vol. 1. Saunders, Philadelphia, PA, 1992.)
  • B. Relations
  • Histology (Figure 1-10)
  • Figure 1-9. Anatomy and relations of the bladder, urethra, uterus and ovary, vagina, and rectum.
  • Figure 1-10. Left: Histology of the prostate. Epithelial glands embedded in a mixture of connective and elastic tissue and smooth muscle. Right: Histology of the bladder. The mucosa is transitional cell in type and lies on a well-developed submucosal layer of connective tissue. The detrusor muscle is composed of interlacing longitudinal, circular, and spiral smooth-muscle bundles.
  • Figure 1-11. Section of the prostate gland shows the prostatic urethra, verumontanum, and crista urethralis, in addition to the opening of the prostatic utricle and the two ejaculatory ducts in the midline. Note that the prostate is surrounded by the prostatic capsule, which is covered by another prostatic sheath derived from the endopelvic fascia. The prostate is resting on the genitourinary diaphragm. (Reproduced, with permission, from Tanagho EA: Anatomy of the lower urinary tract. In: Walsh PC et al [eds] Campbell's Urology, 6th edn., Vol. 1. Saunders, Philadelphia, PA, 1992.)
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Nerve Supply
  • Lymphatics
  • Figure 1-12. Anatomy of the prostate gland (adapted from McNeal JE: The zonal anatomy of the prostate. Prostate 1981;2:35–49). (Reproduced, with permission, from Tanagho EA: Anatomy of the lower urinary tract. In: Walsh PC et al [eds] Campbell's Urology, 6th edn., Vol. 1. Saunders, Philadelphia, PA, 1992.) Prostatic adenoma develops from the periurethral glands at the site of the median or lateral lobes. The posterior lobe, however, is prone to cancerous degeneration.
  • SEMINAL VESICLES
  • Gross Appearance
  • Histology
  • Blood Supply
  • Nerve Supply
  • Lymphatics
  • SPERMATIC CORD
  • Gross Appearance
  • Histology
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Lymphatics
  • EPIDIDYMIS
  • Gross Appearance
  • A. Anatomy
  • B. Relations
  • Histology
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Lymphatics
  • TESTIS
  • Gross Appearance
  • A. Anatomy
  • B. Relations
  • Histology(Figure 1-7)
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Lymphatics
  • SCROTUM
  • Gross Appearance
  • Histology
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Lymphatics
  • PENIS AND MALE URETHRA
  • Gross Appearance
  • Histology
  • A. Corpora and Glans Penis
  • B. Urethra
  • Blood Supply
  • A. Arterial
  • B. Venous
  • Lymphatics
  • FEMALE URETHRA
  • Gross Appearance
  • Histology
  • Blood Supply
  • Lymphatics
  • BIBLIOGRAPHY
  • Adrenals
  • Kidneys
  • Calices, Renal Pelvis, and Ureter
  • Bladder
  • Prostate Gland
  • Spermatic Cord and Seminal Vesicles
  • Testis, Scrotum, and Penis
  • Female Urethra
  • 2 Embryology of the Genitourinary System
  • NEPHRIC SYSTEM
  • Pronephros
  • Mesonephros
  • Metanephros
  • Figure 2-1. Schematic representation of the development of the nephric system. Only a few of the tubules of the pronephros are seen early in the 4th week, while the mesonephric tissue differentiates into mesonephric tubules that progressively join the mesonephric duct. The first sign of the ureteral bud from the mesonephric duct is seen. At 6 weeks, the pronephros has completely degenerated and the mesonephric tubules start to do so. The ureteral bud grows dorsocranially and has met the metanephrogenic cap. At the 8th week, there is cranial migration of the differentiating metanephros. The cranial end of the ureteric bud expands and starts to show multiple successive outgrowths. (Adapted from several sources.)
  • Molecular Mechanisms of Renal and Ureteral Development
  • Figure 2-2. Progressive stages in the differentiation of the nephrons and their linkage with the branching collecting tubules. A small lump of metanephric tissue is associated with each terminal collecting tubule. These are then arranged in vesicular masses that later differentiate into a uriniferous tubule draining into the duct near which it arises. At one end, Bowman's capsule and the glomerulus differentiate; the other end establishes communication with the nearby collecting tubules.
  • ANOMALIES OF THE NEPHRIC SYSTEM
  • VESICOURETHRAL UNIT
  • Figure 2-3. The development of the ureteral bud from the mesonephric duct and the relationship of both to the urogenital sinus. The ureteral bud appears at the 4th week. The mesonephric duct distal to this ureteral bud is gradually absorbed into the urogenital sinus, resulting in separate endings for the ureter and the mesonephric duct. The mesonephric tissue that is incorporated into the urogenital sinus expands and forms the trigonal tissue.
  • Figure 2-4. Differentiation of the urogenital sinus in males. At the 5th week, the progressively growing urorectal septum separates the urogenital sinus from the rectum. The former receives the mesonephric duct and the ureteral bud. It retains its tubular structure until the 12th week, when the surrounding mesenchyme starts to differentiate into the muscle fibers around the whole structure. The prostate gland develops as multiple epithelial outgrowths just above and below the mesonephric duct. During the 3rd month, the ventral part of the urogenital sinus expands to form the bladder proper; the pelvic part remains narrow and tubular, forming part of the urethra. (Reproduced, with permission, from Tanagho EA, Smith DR: Mechanisms of urinary continence. 1. Embryologic, anatomic, and pathologic considerations. J Urol 1969;100:640.)
  • Figure 2-5. Differentiation of the urogenital sinus and the Müllerian ducts in the female embryo. At 9 weeks, the urogenital sinus receives the fused Müllerian ducts at Müller's tubercle (sinovaginal node), which is solidly packed with cells. As the urogenital sinus distal to Müller's tubercle becomes wider and shallower (15 weeks), the urethra and fused Müllerian duct will have separate openings. The distal part of the urogenital sinus forms the vaginal vestibule and the lower fifth of the vagina (shaded area), and that part above Müller's tubercle forms the urinary bladder and the entire female urethra. The fused Müllerian ducts form the uterus and the upper four-fifths of the vagina. The hymen is formed at the junction of the sinovaginal node and the urogenital sinus.
  • PROSTATE
  • ANOMALIES OF THE VESICOURETHRAL UNIT
  • GONADS
  • Descent of the Gonads
  • A. Testis
  • B. Ovary
  • GONADAL ANOMALIES
  • GENITAL DUCT SYSTEM
  • MALE DUCT SYSTEM
  • Epididymis
  • Vas Deferens, Seminal Vesicles, and Ejaculatory Ducts
  • FEMALE DUCT SYSTEM
  • ANOMALIES OF THE GONADAL DUCT SYSTEM
  • EXTERNAL GENITALIA
  • MALE EXTERNAL GENITALIA
  • Figure 2-6. Transformation of the undifferentiated genital system into the definitive male and female systems.
  • FEMALE EXTERNAL GENITALIA
  • ANOMALIES OF THE EXTERNAL GENITALIA
  • BIBLIOGRAPHY
  • General
  • Anomalies of the Nephric System
  • Anomalies of the Vesicourethral Unit
  • Gonadal Anomalies
  • 3 Symptoms of Disorders of the Genitourinary Tract
  • SYSTEMIC MANIFESTATIONS
  • LOCAL AND REFERRED PAIN
  • Kidney Pain (Figure 3-1)
  • Figure 3-1. Referred pain from kidney (dotted areas) and ureter (shaded areas).
  • Ureteral Pain (Figure 3-1)
  • Figure 3-2. Diagrammatic representation of autonomic nerve supply to gastrointestinal and genitourinary tracts.
  • Figure 3-3. Diagrammatic representation of sensory nerves of gastrointestinal and genitourinary tracts.
  • Vesical Pain
  • Prostatic Pain
  • Testicular Pain
  • Epididymal Pain
  • GASTROINTESTINAL SYMPTOMS OF UROLOGIC DISEASES
  • Cause of the Mimicry
  • A. Renointestinal Reflexes
  • B. Organ Relationships
  • C. Peritoneal Irritation
  • SYMPTOMS RELATED TO THE ACT OF URINATION
  • Frequency, Nocturia, and Urgency
  • Dysuria
  • Enuresis
  • Symptoms of Bladder Outlet Obstruction
  • A. Hesitancy
  • B. Loss of Force and Decrease of Caliber of the Stream
  • C. Terminal Dribbling
  • D. Urgency
  • E. Acute Urinary Retention
  • F. Chronic Urinary Retention
  • G. Interruption of the Urinary Stream
  • H. Sense of Residual Urine
  • I. Cystitis
  • Incontinence (See also Chapter 27)
  • A. True Incontinence
  • B. Stress Incontinence
  • C. Urge Incontinence
  • D. Overflow Incontinence
  • Oliguria and Anuria
  • Pneumaturia
  • Cloudy Urine
  • Chyluria
  • Bloody Urine
  • A. Bloody Urine in Relation to Symptoms and Diseases
  • B. Time of Hematuria
  • OTHER OBJECTIVE MANIFESTATIONS
  • Urethral Discharge
  • Skin Lesions of the External Genitalia (See Chapters 15 and 40)
  • Visible or Palpable Masses
  • Edema
  • Bloody Ejaculation
  • Gynecomastia
  • COMPLAINTS RELATED TO SEXUAL PROBLEMS
  • Sexual Difficulties in Men
  • Sexual Difficulties in Women
  • BIBLIOGRAPHY
  • 4 Physical Examination of the Genitourinary Tract
  • EXAMINATION OF THE KIDNEYS
  • Inspection
  • Palpation
  • Percussion
  • Transillumination
  • Figure 4-1. Method of palpation of the kidney. The posterior hand lifts the kidney upward. The anterior hand feels for the kidney. The patient then takes a deep breath; this causes the kidney to descend. As the patient inhales, the fingers of the anterior hand are plunged inward at the costal margin. If the kidney is mobile or enlarged, it can be felt between the two hands.
  • Differentiation of Renal and Radicular Pain
  • Auscultation
  • EXAMINATION OF THE BLADDER
  • EXAMINATION OF THE EXTERNAL MALE GENITALIA
  • Penis
  • A. Inspection
  • B. Palpation
  • C. Urethral Discharge
  • Scrotum
  • Testis
  • Epididymis
  • Spermatic Cord and Vas Deferens
  • Testicular Tunics and Adnexa
  • EXAMINATION OF THE FEMALE GENITALIA
  • Vaginal Examination
  • A. Inspection
  • B. Palpation
  • RECTAL EXAMINATION IN MALES
  • Sphincter and Lower Rectum
  • Prostate
  • A. Size
  • B. Consistency
  • Figure 4-2. Differential diagnosis of prostatic nodules. A: Inflammatory area is raised above the surface of the gland; induration decreases gradually at its periphery. B: Cancerous nodules is not raised; there is an abrupt change in consistency at its edges.
  • C. Mobility
  • D. Massage and Prostatic Smear
  • Seminal Vesicles
  • Lymph Nodes
  • A. Inguinal and Subinguinal Lymph Nodes
  • B. Other Lymph Nodes
  • NEUROLOGIC EXAMINATION
  • BIBLIOGRAPHY
  • Examination of the Kidneys
  • External Genitalia in Males
  • External Genitalia in Females
  • Prostate
  • Neurologic Examination
  • 5 Urologic Laboratory Examination
  • EXAMINATION OF URINE
  • Urine Collection
  • A. Timing of Collection
  • B. Method of Collection
  • Macroscopic Examination
  • A. Color and Appearance
  • B. Specific Gravity
  • C. Chemical Tests
  • Microscopic Examination
  • Figure 5-1. Microscopic examination of urine sediment. (Redrawn after Todd-Sanford-Davidson.)
  • A. Interpretation
  • Figure 5-2. Left: Dysmorphic erythrocytes in urine (arrows), viewed under light microscopy (magnification ×400). Right: Dysmorphic erythrocytes in urine (identical field), viewed under phase-contrast microscopy. (Reproduced, with permission, from Stamey TA, Kindrachuk RW: Urinary Sediment and Urinalysis: A Practical Guide for the Health Science Professional. WB Saunders, Philadelphia, PA, 1985.)
  • Bacteriuria
  • A. Microscopic Examination
  • B. Bacterial Cultures
  • Figure 5-3. Papanicolaou-stained bladder cytology specimens. A: Normal cells (left) and malignant cells (right). B: High-power view of malignant cells. C: Papillary cluster of malignant cells. (Courtesy of Larry Kluskens, MD, Cytopathology Laboratory, University of Iowa.)
  • Other Urine Tests
  • A. Urothelial Cancer Tests
  • Table 5-1. Comparison of different urine tests for bladder transitional cell carcinoma.
  • B. Prostate Cancer Tests
  • C. Hormonal Studies
  • D. Studies of Stone Constituents
  • E. Miscellaneous Studies
  • EXAMINATION OF URETHRAL DISCHARGE AND VAGINAL EXUDATE
  • Urethral Discharge
  • Vaginal Exudate
  • RENAL FUNCTION TESTS
  • Urine Specific Gravity
  • Serum Creatinine
  • Endogenous Creatinine Clearance
  • Blood Urea Nitrogen
  • EXAMINATION OF BLOOD, SERUM, AND PLASMA
  • Complete Blood Count
  • Blood Clotting Studies
  • Electrolyte Studies
  • Prostate Cancer Markers
  • Hormonal Studies
  • Other Studies
  • LABORATORY VALUES IN ELDERLY PATIENTS
  • Table 5-2. Laboratory values that do not change with age.
  • Table 5-3. Laboratory values that do change with age.
  • Bibliography
  • 6 Radiology of the Urinary Tract
  • RADIOGRAPHY
  • Basic Equipment and Techniques
  • Advantages and Disadvantages
  • Intravenous Urography
  • Figure 6-1. Plain films of the abdomen with abnormal radiopacities. Upper left: Bilateral nephrocalcinosis. Young adult male with renal tubular acidosis. Upper right: Bilateral staghorn calculi. 37-year-old woman with chronic pyelonephritis and history of previous right staghorn pyelolithotomy. Lower left: Renal tuberculosis. Shrunken, autonephrectomized, and calcified right tuberculous kidney (arrows). 74-year-old man with history of renal and thoracolumbar spinal tuberculosis. Lower right: Papillary adenocarcinoma of right kidney. Remarkable tumor surface calcifications. Multiple pulmonary metastases (arrows) from the renal cancer. 22-year-old woman with painless soft tissue mass in the neck.
  • A. Patient Preparation
  • B. Standard Technique
  • C. Technique Modifications
  • Figure 6-2. Plain films of the abdomen with abnormal radiopacities. Left: Schistosomiasis calcification (arrows) in bladder and left ureter. 19-year-old male native of Aden with weight loss and hematuria. Right: Large vaginolith (open arrow) and small, barely visible bladder calculus (solid arrow). 4-year-old girl with common urogenital sinus.
  • Figure 6-3. Plain films of the abdomen with abnormal radiolucencies. Left: Emphysematous pyelonephritis. Interstitial striated pattern of radiolucent gas throughout the entire left kidney. Similar changes were present in the right kidney. 58-year-old diabetic man with pyuria and septic shock. Right: Gas pyelogram. No interstitial gas, but gas fills dilated left kidney calices, pelvis, and ureter. 50-year-old diabetic woman with sepsis and left upper urinary tract infection due to gas-forming micro-organisms.
  • Figure 6-4. Abnormal excretory urograms. Left: Medullary sponge kidney. Pronounced medullary tubular ectasia (arrows) of entire right kidney. Similar findings were present in upper pole pyramids of left kidney, and small medullary calculi were present in some areas of tubular ectasia in both kidneys. 34-year-old woman with repeated bouts of chills, fever, and left flank pain. Right: Renal tuberculosis. Irregular cavitation of lower pole pyramid (arrow). 22-year-old woman with positive urine culture for tuberculosis.
  • Figure 6-5. Abnormal excretory urograms. Left: Crossed fused ectopia. Composite of 2 films from an excretory urogram shows ectopic right kidney (R) fused to left kidney (L). Right ureter (arrows) crosses midline and enters normally into right side of bladder. Healthy 31-year-old female potential kidney donor. Right: Infantile polycystic kidney disease. Very large kidneys with radiopaque spoke pattern radiating out to cortex. 26 hours after administration of intravenous contrast medium. 4-month-old girl with bilateral abdominal masses.
  • Figure 6-6. Radiographic tomography. Tomography is used to image a plane in the body. The technique was widely used in uroradiology, often permitting demonstration of lesions otherwise hidden by overlying soft tissues or obscuring bowel shadows. However, computed tomography (CT) is rapidly replacing conventional excretory urograms, and thus tomography is declining in its use as well. Left: Transitional cell carcinoma. The tumor in the pelvis (arrow) is clearly shown free of obscuring gas shadows present on the nontomographic films. 56-year-old man with history of renal calculi. Right: Renal cell carcinoma (T). Displacement of mid-kidney collecting structures and a nephrogram defect are seen free of obscuring splenic flexure fecal shadows that were present on the nontomographic films. 44-year-old woman with fever, weight loss, anemia, and history of contralateral nephrectomy for carcinoma 15 years earlier.
  • Retrograde Urograms
  • Percutaneous Urograms
  • Figure 6-7. Retrograde urograms and nephrostograms; lower ureters not all shown. Upper left: Normal retrograde urogram. Intrarenal collecting structures, pelvis, and ureter are normal. Adult male with microscopic hematuria and previous technically unsatisfactory excretory urogram. Upper right: Squamous cell carcinoma. Marked irregular filling defects involving calices, pelvis, and proximal ureter, with communicating abscess cavity in upper pole (arrow). Kidney also showed squamous meta-plasia and contained calculi. 51-year-old woman with 2-week history of left flank cellulitis and tenderness. Lower left: Transitional cell carcinoma. Severe deformity with filling defects in right upper pole calices (curved arrow) and blood clots in lower calices and at ureteropelvic junction (straight arrow). 65-year-old man with gross hematuria and right flank pain. Lower right: Fungus balls. Nephrostogram revealing 2 filling defects (arrows) in renal pelvis. Copious fungal matter aspirated through nephrostomy catheter. 65-year-old diabetic woman who had undergone left nephrectomy, with percutaneous nephrostomy catheter (white arrow) for obstruction of right kidney.
  • Figure 6-8. Abnormal retrograde urograms. Upper left: Idiopathic retroperitoneal fibrosis. Smooth narrowing of both mid ureters (arrows), with bilateral proximal ureterectasis and hydronephrosis. 51-year-old woman with no urinary tract symptoms. Upper right: Functional ureteral obstruction. Obstruction was due to congenitally abnormal muscle arrangements in the affected very distal ureter (curved arrow). Pronounced hydronephrosis and dilatation of ureter (U) proximal to the short segment of abnormal ureter. 13-year-old boy with repeated urinary tract infections. Lower left: Transitional cell carcinoma of the ureter. No contrast medium has passed beyond the large, bulky, right ureteral tumor (arrow). The ureteral widening below the tumor is distinctive and is sometimes referred to as the "champagne glass" sign (in this instance, the glass is tipped on its side). 76-year-old man with nonfunctioning right kidney. Lower right: Ureteral constrictions secondary to extension of carcinoma of the colon. Bilateral distal ureteral narrowings (arrows) with upper tract obstruction. Composite of separate retrograde urograms. E = unintended extravasation about tip of left ureteral catheter. 76-year-old man with cancer of the sigmoid colon.
  • Figure 6-9. Normal voiding cystourethrograms. Left: Normal female bladder and urethra. Arrow indicates urethral meatus. 22-year-old woman with voiding symptoms. Right: Normal male penile urethra. Large open arrow = prostatic urethra; small open arrow = membranous urethra; closed arrow = penile urethra; curved arrow = verumontanum. 27-year-old man with vague right lower abdominal and testicular pain.
  • Figure 6-10. Abnormal cystograms: retrograde cystograms or "cystograms" as part of excretory urogram studies. Upper left: Ectopic ureterocele. Giant ureterocele (straight arrows) to hydronephrotic, nonfunctioning upper portion (curved arrow) of duplex right kidney. 9-month-old-girl with urinary tract infections. Upper right: Pelvic lipomatosis. Pear-shaped bladder and increased radiolucency of the pelvic soft tissues secondary to pelvic lipomatosis of severity sufficient to produce obstructive dilatation of the upper urinary tracts. Filling defects (arrows) at bladder base due to cystitis glandularis. 62-year-old man with intermittent left flank pain. Lower left: Rupture of the membranous urethra. Pear-shaped bladder secondary to extraperitoneal extravasation (E) and perivesical hematoma. Arrow = inflated balloon of Foley catheter. 41-year-old man with renal transplant, after a motor vehicle accident that resulted in pelvic bone fractures, separation of the sacroiliac joints, and dislocation of the left (L) but not the right hip prosthesis (patient has bilateral hip prostheses). Lower right: Bladder hernia. Bilateral obstructive ureterectasis (small arrows) secondary to remarkable herniation of the entire bladder (large arrow, B) into the inguinal region, 5″ 5′, 225 lb, 53-year-old man with panniculus reaching to mid thigh, complaining of difficulty voiding.
  • Figure 6-11. Abnormal cystograms: retrograde cystograms or "cystograms" as part of excretory urogram studies. Upper left: Neurogenic bladder. This neurogenic bladder has a "Christmas-tree" shape, with gross trabeculation and many diverticula. Residual myelographic contrast medium in spinal canal (straight arrow). Right vesicoureteral reflux (curved arrow). 70-year-old man with urinary incontinence. Upper right: Congenital "hourglass" bladder. Transverse concentric muscular band (arrows) separates upper and lower bladder segments, both of which contracted and emptied simultaneously and completely with voiding. 66-year-old woman with urinary stress incontinence. Lower left: Hodgkin's disease of bladder. Global thickening of the bladder wall (arrows), more apparent on the left. 54-year-old man with generalized Hodgkin's disease. Lower right: Papillary transitional cell bladder carcinoma. Huge (12 cm) cauliflower-like bladder mass (arrows) filling almost the entire bladder. "Cystogram" film of an excretory urogram in a 40-year-old man with recurrent bladder tumor.
  • Figure 6-12. Abnormal prostate and posterior urethra: cystograms and urethrograms. Upper left: Benign prostatic hyperplasia. Gross enlargement of prostate gland producing marked elevation (arrows) of the bladder base. The bladder shows small diverticula and slight trabeculation. Excretory urogram (cystogram) in a 65-year-old man with history of obstructive voiding symptoms. Upper right: Foreign body (eyeliner pencil cover) lodged in bladder and prostatic urethra, with urethrorectal fistula. Radiopaque medium enters rectum and sigmoid colon (S) through fistula (arrow) from prostatic urethra. Retrograde urethrogram in a 43-year-old man. Lower left: Rhabdomyosarcoma of prostate. Lobulated filling defects (large arrow) encroaching on widened prostatic urethra. Voiding cystourethrogram in a 5-year-old boy with voiding difficulties. Small arrow = penile urethra. Lower right: Posterior urethral valves. Marked dilatation and elongation of prostatic urethra (P), with reflux into prostatic ducts (straight arrow) secondary to posterior urethral valves (curved arrow) with bilateral vesicoureteral reflux into dilated ureters (U). Voiding cystourethrogram in a 10-day-old boy.
  • Figure 6-13. Abnormal anterior urethras: voiding cystourethrograms and retrograde urethrograms. Upper left: Voiding cystourethrogram in a 78-year-old man with a history of urethral diverticulum of unknown etiology. 4-cm anterior urethral diverticulum (large arrow) and left vesicoureteral reflux (small arrow). Upper right: Urethral diverticulum in a woman. Large irregular diverticulum (arrow). Voiding cystourethrogram in a 51-year-old woman with voiding difficulties and suspected urethral stricture. Lower left: Ruptured urethra. Extravasation of contrast medium around the membranous urethra (arrows). Retrograde urethrogram in a 16-year-old boy in whom blunt perineal trauma was followed by bloody urethral discharge and inability to void. Lower right: Urethroscrotal fistula. Extravasation (E) into extraurethral tissues from fistula in bulbous urethra (arrow). Retrograde urethrogram in a 26-year-old man after end-to-end urethroplasty for stricture.
  • Figure 6-14. Abnormal anterior urethras: retrograde urethrograms. Left: Urethral carcinoma. Filling of irregular sinus tracts and channels in a large epidermoid carcinoma of the bulbocavernous urethra (straight arrow). There are multiple thin transverse strictures of the penile urethra (curved arrow). 75-year-old man with obstructive voiding symptoms and 30-year history of urethral strictures requiring dilatations. Right: Focal urethral stricture (arrow). Middle-aged man with obstructive voiding symptoms who denied previous urethritis.
  • Aortorenal and Selective Renal Arteriography (Figure 6-17)
  • Inferior Venacavography and Selective Venography (Figures 6-18 and 6-19)
  • Miscellaneous Urologic Angiography
  • Figure 6-15. Congenital genitourinary anomalies: voiding cystograms and retrograde urethrograms. Upper left: Utricle. Midline outpouching (arrow) from verumontanum between orifices of ejaculatory ducts, representing Müllerian duct cyst. Upper right: Gas cystogram combined with injection of utricle, oblique view. M = grossly dilated utricle (Müllerian duct cyst); straight arrows = bladder distended with air; curved arrow = coincident partial filling of left seminal vesicle and vas deferens. 34-year-old man with urgency, frequency, and suspected retrograde ejaculation. Lower left: Common urogenital sinus. Vagina (V) and urethra (U) join (at arrow) into a common urogenital sinus (S). Voiding cystourethrogram in a 3-week-old female pseudohermaphrodite with ambiguous genitalia and congenital adrenal hyperplasia. Lower right: Male pseudohermaphrodite. Bladder is distended with urine (black arrows). Retrograde urethrogram via hypospadiac meatus has fortuitously and selectively filled with contrast medium an extensive müllerian duct remnant consisting of vagina (V), cervix and cervical canal (C), and retroverted uterus (U). Residual contrast medium in hypoplastic anterior urethra (white arrow). 27-year-old man with small external genitalia, hypospadias, and perineal pain.
  • Figure 6-16. Vasoseminal vesiculography (vasography). Left: Normal left vasoseminal vesiculogram. V = vas deferens; S = seminal vesicle; E = ejaculatory duct. 40-year-old man with hypospermia. Right: Seminal vesiculitis. Bilateral vasogram. Mass (M) produced by the swollen, nonfilling right seminal vesicle has displaced both ejacula-tory ducts (E) toward the left and indented the medial aspect of the proximal left seminal vesicle and vas deferens (V). 33-year-old man with painful ejaculations after repair of right varicocele.
  • SONOGRAPHY (FIGURES 6-20 THROUGH 6-26)
  • Basic Principles
  • Clinical Applications
  • Figure 6-17. Angiography: aortorenal arteriography. Upper left: Normal abdominal aortogram. The aortic catheter is hidden by the opacified normal aorta. Right (R) and left renal arteries and branches are well shown, as are the splenic (S) and hepatic (H) arteries arising from the celiac axis. The superior mesenteric artery is superimposed over the aortic silhouette and is not visible here. 28-year-old healthy female potential kidney donor. Upper right: Bilateral renal artery stenoses. Typical angiographic appearance and location of stenoses caused by atherosclerosis (small arrows) and fibromuscular dysplasia (large arrows). 58-year-old woman with abdominal bruits and a 16-year history of hypertension. Lower left: 3D coronal CT angiography image demonstrates an inferior accessory left renal artery (posterior view). Lower right: The left accessory renal artery origin (asterisk) is better demonstrated rotating the model in the axial plane. 65-year-old man undergoing preoperative evaluation for laparoscopic partial nephrectomy.
  • Figure 6-18. Angiography: inferior venacavography. Left: Double inferior vena cava (R, L). Persistent left supracardinal vein anomaly. 23-year-old man after orchiectomy for testicular teratocarcinoma. Right: Example of duplicated IVC on IV contrast enhanced axial CT. Normal IVC (arrow) and duplicated IVC (asterisk).
  • Figure 6-19. Angiography: renal venography. Left: Normal left renal vein. On the left side, the adrenal (A) and gonadal (G) veins enter the renal vein (arrow). M = radiographic localization marker. Young woman with proteinuria. Right: Tumor thrombus. Straight arrows = upper margin of filling defect of the renal vein tumor thrombus (T) that extends into the vena cava (C). 68-year-old man with gross hematuria from adenocarcinoma of the right kidney.
  • Figure 6-20. 67-year-old man recently hospitalized for urosepsis. Upper: Transverse color Doppler image of the right (R) and left (L) testicles reveals right-sided hyperemia with associated hypoechoic echotexture and surrounding hypoechoic mass. Middle: Transverse grayscale right hemiscrotal image confirms hypoechoic right testicle (R) and extratesticular complex collection within the epididymal tail (C). Lower: Color Doppler confirms lack of flow within the complex collection. Pathology confirmed chronic granulomatous orchitis, epididymitis and periorchitis.
  • Figure 6-21. Sonography of the kidney. Upper: Normal kidney. Renal cortex (C), normal renal sinus echoes (S). Middle: Moderate hydronephrosis and hydroureter; dilated renal pelvis (P). Dilated proximal ureter (proxure). Lower: Severe hydronephrosis of the transplanted kidney, compound sagittal scans, dilated clubbed calices (C), dilated renal pelvis (P).
  • Figure 6-22. Renal calculus and the consequences of obstruction as detected by sonography. Upper left: Transverse scan of the right kidney showing calicectasis (C) and renal calculus (arrow). Upper right: Acute obstruction of the right kidney (K) with spontaneous urine (U) extravasation into the perirenal space. Renal calculus (arrow).
  • Figure 6-23. Sonography of renal neoplasms. Upper left: Simple renal cyst (Cy) demonstrating sharp interfaces toward the renal parenchyma, no internal echoes, and increase through transmission. Upper right: Complex renal cyst (arrow) with lobulated margins and thick wall. Lower left: Solid tumor (T) in upper pole of left kidney with increased echogenicity relative to adjacent renal parenchyma. Pathology was oncocytoma. Lower right: Solid renal tumor (asterisk) in the right kidney (K) with separate hyperechoic interpolar partially exophytic mass. The interpolar mass represented a known angiomyolipoma, while the upper pole mass represented renal cell carcinoma.
  • Figure 6-24. Sonography with comparative study. Film from IVP (left) and transabdominal ultrasound (right) of the urinary bladder in a patient with duplication of the left kidney, ectopic ureterocele, and a calculus (arrow) within it. Urinary bladder (B).
  • Advantages and Disadvantages
  • Figure 6-25. The use of transrectal ultrasound in the evaluation of the prostatic urethra. Upper left: Sonographic appearance of the prostatic urethra (U) following transurethral resection as seen on transrectal ultrasound in the sagittal plane of scanning. Urinary bladder (B). The urethra (U) is dilated to the level of the verumontanum (arrow). Peripheral zone (P), rectum (R). Upper right: The prostatic urethra (U) is dilated to the level to the membranous urethra (arrow). Urinary bladder (B). The cursors are placed to measure the length of the prostatic urethra. Lower left and lower right: Examples of testicular ultrasound. Lower left: The right testis (T) is normal. There is a hypoechoic lesion within the left testis (asterisk). At surgery, it was a seminoma. Lower right: A large mixed solid and cystic intratesticular mass with foci of echogenic calcifications. Benign epidermoid cyst. This mass did not show concentric lamellation sometimes associated with epidermoid cysts. Ultrasound cannot always differentiate epidermoid cysts from malignant germ cell neoplasms.
  • COMPUTED TOMOGRAPHY SCANNING (FIGURES 6-27 THROUGH 6-33)
  • Basic Principles
  • Figure 6-26. Gray-scale and Doppler sonography: acute rejection in a renal transplant. Upper left: Gray-scale ultrasound image of transplant kidney shows poor corticomedullary differentiation. A small fluid collection is seen within the renal pelvis (arrow). Native external iliac vessels are seen as tubular hypoechoic structures (arrowheads). Upper right and lower left: Color Doppler images demonstrate flow within the native external iliac artery (arrowheads), the transplant renal artery (long arrow), and the interlobar arteries (short arrow). Lower right: Spectral Doppler analysis reveals an elevated resistive index of 0.84. These findings are compatible with, but not specific for, acute rejection. In the nonacute setting, cyclosporin toxicity or chronic rejection may also show elevated arterial resistive indices.
  • Clinical Applications
  • Figure 6-27. CT scans: adrenal glands. Upper left: Normal adrenal glands (arrows) have inverted arrowhead or Y shape Upper right: CT densitometry. Thin section CT of incidental right adrenal mass (M) performed without intravenous contrast. Region of interest density measurement was below 10 Hounsfield Units (near zero), compatible with adrenal adenoma, confirmed by pathology. Mid left: Bilateral adrenal lymphoma. Enlarged adrenal glands (arrows) anterior to normal kidneys. L = liver. 53-year-old man with abdominal pain and histiocytic lymphoma of the central nervous system. Mid right: Left adrenal carcinoma. Large tumor (T) in left upper retroperitoneum with necrotic or cystic changes. Differential for CT included exophytic renal carcinoma. 52-year-old female with pulmonary nodules (metastases). Lower left: Axial CT image reveals a predominant solid mass (arrow) abutting the left kidney, with areas of cystic change. Lower right: Coronal oblique reformatted image from the same patient shows the mass (arrow) to be inseparable from the inferior left adrenal limb (asterisk). Pathologically proven adrenal carcinoma.
  • Figure 6-28. CT scans: kidneys. Left: Simple renal cyst. Cyst (arrow) has a CT number close to that of water. 49-year-old man with flank pain. Right: New Hydronephrosis, severe on left and mild on right. Dilated left renal pelvis and delayed left nephrogram (arrow). 40-year-old female with ovarian carcinoma and peritoneal metastases.
  • Advantages and Disadvantages
  • Figure 6-29. CT scans: kidneys. Upper left: Renal cell carcinoma. The left renal tumor (arrow) shows central necrosis. Note calcification in the arteriosclerotic abdominal aorta. 61-year-old man with previous right nephrectomy for renal carcinoma. Upper right: Recurrent renal adenocarcinoma. Massive recurrence in right renal fossa (T), with extensive invasion of posterior soft tissues and destruction of vertebral bodies (arrows). 51-year-old man after right nephrectomy for carcinoma. Mid left: Renal angiomyolipomas. Bilateral heterogeneous renal masses. The larger lesions all showed areas of macroscopic fat density (arrows). 35-year-old female with probable lymphangioleiomyomatosis. Mid right: Right renal pelvic laceration. Enhanced CT scan through the kidneys showing extravasation of radiopaque material (arrow). Hemorrhage into the psoas and back muscles has enlarged their image (asterisk). 22-year-old man with laceration of the right renal pelvis due to a stab wound. Lower left: Large palpable heterogeneous left renal mass, with confirmed hemorrhage with subcapsular extension. Wilm's tumor in a 9-year-old female with acute onset fever and abdominal pain. Lower right: Large retroperitoneal neuroblastoma, encasing vessels.
  • Figure 6-30. CT scans: kidneys. Upper left: Transitional cell carcinoma. Delayed image CT urogram demonstrates an irregular nodular filling defect in the right upper collecting system (arrow). Upper right: 42-year-old woman with severe right pyelonephritis. An image through the mid pole of the right kidney reveals an enlarged kidney with marked destruction and striation of the renal parenchyma. Note the multiple low-density fluid collections. Lower left: Exophytic renal cell carcinoma. An image through the mid left kidney shows a mass that may be of renal cortical or collecting system origin. Lower right: A lower image in the same patient reveals that the mass arises from the kidney, as the contrast-containing collecting system is splayed by the mass. The renal vein is displaced anteriorly by the mass, but was free of thrombus.
  • MAGNETIC RESONANCE IMAGING (FIGURES 6-34 THROUGH 6-41)
  • Basic Principles
  • Figure 6-31. 3D computed tomography (CT) and CT angiography (CTA) for renal mass, performed on multidetector CT scanner. Coronal oblique reformatted image with volume rendering shows a small enhancing mass (M) in the lower pole of the left kidney. The kidney has 2 renal arteries (arrows). The lower one, which serves the tumor, is the primary artery. 69-year-old male with solitary kidney and indeterminate lesion on prior CT.
  • Clinical Applications
  • Figure 6-32. Helical computed tomography (CT) without oral or intravenous contrast in a 42-year-old man with left flank pain. Left: CT image through the kidneys shows enlargement of the left kidney compared with the right, left pelvocaliectasis (P), and a stone in the mid pole of the left kidney (arrow). L = liver, S = spleen. Right: CT image through the base of the bladder shows an 8-mm stone (arrow) at the left ureterovesical junction with associated edema involving the left hemitrigone. Posterior to the ureteral stone is a 5-mm phlebolith (open arrow) within a pelvic vein.
  • Figure 6-33. CT scans: retroperitoneum, bladder, prostate. Upper left: Perirenal hematoma. Hematoma (arrow) displaces the left kidney anteriorly. G = gallbladder. 16-year-old boy with acute glomerulonephritis; low-grade fever and left flank pain following left renal biopsy. Upper right: Retroperitoneal metastatic seminoma. Large retroperitoneal mass of metastatic nodes (T) destroying vertebral body (arrow), obliterating outlines of central abdominal and retroperitoneal structures, and displacing kidneys laterally and bowel anteriorly. 46-year-old man with metastatic anaplastic testicular seminoma. Middle left: CT scan, transitional cell carcinoma of the urinary bladder with tumor (T) extension into the bladder diverticulum. There is tumor extension into the perivesical fat (arrows). Middle right: CT urogram in arterial phase, enhancing 5-mm transitional cell carcinoma of the urinary bladder (arrow). Lower left: Ureteritis cystica on CT urogram. Punctate rounded filling defect (arrow) in left renal pelvis on 12-minute delayed excretion images after intravenous contrast administration. Lower right: Coronal delayed reformat demonstrates other similar punctate collecting system filling defects. 77-year-old female after cystectomy on surveillance with stable, multiple punctate rounded filling defects bilaterally and negative urine cytology.
  • Figure 6-34. Magnetic resonance imaging (MRI) appearance of the normal kidney. Upper left: T1-weighted conventional spin-echo image showing detailed anatomy of the kidney with differentiation between higher signal intensity cortex (C) and lower signal intensity medulla (M). Left renal vein (arrow), inferior vena cava (I). Upper right: T1-weighted spin-echo image using fat saturation technique. Because the fat signal has been suppressed, the computer automatically adjusts the gray scale of the signal intensity rendering even better contrast between higher signal intensity cortex (C) and lower signal intensity medulla (M). Lower left: Coronal T2-weighted image shows multiple renal and hepatic cysts (asterisk), as well as a partially solid and cystic left renal mass (T) in this adult female with polycystic kidney disease. Lower mid: Noncontrast T1-weighted fat saturation volume acquisition scan, used for dynamic imaging. The left renal mass is subtle on this precontrast scan (asterisk). Lower right: Arterial phase scan obtained following gadolinium-DTPA injection of contrast medium. The left renal mass (asterisk) shows avid enhancement of solid components. The addition of gadolinium adds significant soft tissue contrast.
  • Figure 6-35. Magnetic resonance (MR) images Upper left and upper right: Horseshoe kidney. Nonenhanced T1-weighted image (upper left); m, medulla; c, renal cortex. Gadolinium-DTPA-enhanced T1-weighted image (upper right). Following injection of the contrast medium, there is uniform enhancement of the renal cortex (C). The addition of the contrast enhancement shows that the part of the kidney in front of the aorta (A) and the inferior vena cava (I) is functioning renal parenchyma. Middle left and lower right: Chemical shift imaging, adrenal adenoma. On in-phase gradient T1-weighted image (left) there is a soft tissue intensity 2.7-cm mass in the left adrenal gland (arrow). Opposed phase T1-weighted image (right) shows marked signal loss in the lesion consistent with intracellular lipid; and therefore, a benign adenoma. 30-year-old female with indeterminate adrenal lesion noted on prior computed tomography (CT). Lower left: Biopsy-proven angiomyolipoma. Axial T1-weighted gradient echo in-phase imaging reveals a mass (T) arising off anterior interpolar left kidney. Renal contour defect (arrow) noted where mass originates. Lower right: Postintravenous gadolinium fat saturation T1-weighted image reveals a large amount of low-signal-intensity fat within the mass as well as vascular supply (arrow) arising via vessels extending from a defect in the renal cortex.
  • Figure 6-36. Magnetic resonance imaging (MRI) appearance of renal cell carcinoma. The advantages of MRI are multiplanar imaging and the use of contrast media for better tumor characterization. Upper left: Sagittal T1-weighted image demonstrating a large renal cell carcinoma (T) arising from the inferior pole of the right kidney (K). Tumor extension in the posterior perirenal space (arrow). Liver (L). Upper right: Coronal image of a large renal cell carcinoma (T) replacing almost entire parenchyma of the left kidney (K). Superior displacement of the pancreas (arrows). Liver (L). Lower left and lower right: Fat saturation images before and after injection of the contrast medium. Heterogeneous tumor (lower right) in the posterior part of the right kidney shows heterogeneous enhancement following injection of gadolinium. The tumor is extending into the renal vein (arrows) and to the inferior vena cava (I).
  • Figure 6-37. 42-year-old female with abdominal pain after karate kick with gross hematuria. Upper left: Axial T1-weighted out-of-phase gradient echo image reveals high T1 signal intensity indicative of hemorrhage within a left renal lesion (asterisk), confirmed as cystic on other sequences. Upper middle: Coronal T1 fat saturation image after intravenous gadolinium administration shows lack of cyst enhancement (asterisk). Upper right: Delayed postcontrast imaging confirms communication with collecting system, showing cyst contents filling with high signal gadolinium (asterisk). Hemorrhage within a calyceal diverticulum after trauma. Lower images: Pre- and postcontrast and magnetic resonance imaging (MRI) of a renal cell carcinoma adjacent to a cyst in another patient Lower left: Precontrast T1-weighted image shows similar intensities for the cyst, tumor, and normal renal parenchyma. Lower right: Postcontrast T1-weighted image. The cyst (long arrow) is nonenhancing. The margins of the enhancing renal cell carcinoma (short arrows) are seen. The central fluid collection does not enhance.
  • Figure 6-38. Gadolinium-enhanced renal magnetic resonance angiography (MRA). Left: Maximum intensity projection (MIP) image from a renal MRA in a 22-year-old potential renal donor. The renal arteries are normal. Right: MIP image from a renal MRA in a 56-year-old man with suspected renovascular hypertension shows an atrophic left kidney with an occluded left renal artery (arrow) and a severely stenotic right renal artery (open arrow). The collateral capsular renal vessels are not seen. A = aorta, I = inferior vena cava.
  • Figure 6-39. Magnetic resonance imaging (MRI) examination of the pelvis. The upper images are examples of the ability of MRI to evaluate bladder neoplasms. Upper left: Axial T2-weighted image. A large anterior bladder tumor (T) shows associated perivesicular fat stranding (asterisk), raising the suspicion for extension through the muscularis. A prominent vessel (arrow) in the left obturator region exited through the obturator foramen on more inferior images. Upper right: T2-weighted sagittal image. The tumor (asterisk) extends into the urachal remnant (arrow). Middle and lower rows: Prostate cancer. Axial T2-weighted image (middle left) shows dominant right mid-gland peripheral and transition zone tumor with gross posterior extracapsular extension (arrow). Superimposed spectroscopy confirms depleted citrate (asterisk) compared to the adjacent choline and creatine peaks in the region of tumor (middle right). Lower left: Axial T2-weighted image in another patient demonstrates a large left mid-gland lesion (T) with associated capsular indistinctness and irregularity. Lower right: Apparent diffusion coefficient mapping confirms restricted diffusion within the tumor (T). Gleason 4 + 3 biopsy proven tumor in up to 75% of cores.
  • Figure 6-40. Magnetic resonance imaging (MRI) of seminal vesicles, ductus deferens, and ejaculatory ducts. Upper left: T2-weighted image, normal seminal vesicles, and ductus deferens, and ejaculatory ducts. The ampullae of the ductus deferens (long arrows) are normally of high signal intensity on T2-weighted images and are immediately medial to the seminal vesicles (short arrows). The seminal vesicles are also of high signal intensity and are draped over the prostate gland. Upper right: Seminal vesicle and ductus deferens calculi. Coronal T2-weighted images show low-signal calculi within the proximal ductus deferens and medial aspect of the seminal vesicle on the left side (arrows). The patient had a history of prostatitis, prostatic pain, and hemorrhagic ejaculate. Lower left: Axial T2-weighted image through the prostate. The peripheral zone is of normal high signal intensity. The normal ejaculatory ducts (arrows) are identified as two small foci ducts of high-signal-intensity within the lower signal central zone. Lower right: Axial T2-weighted image through the prostate reveals a low-signal-intensity calculus (arrow) within the right ejaculatory duct (same patient as in upper right image).
  • Figure 6-41. Magnetic resonance imaging (MRI) appearance of scrotal contents. Upper left: Normal testis, T2-weighted image. The testicular tissue is of homogeneous high signal intensity. The tunica albuginea (arrows) demonstrates low signal intensity as does the mediastinum testis (open arrowhead). A small amount of fluid-hydrocele (H). Epididymis (E) is of low signal intensity. Upper right: Hydrocele of the right scrotum (T2-weighted image). Hydrocele (H) demonstrates high signal intensity. Testis (T). Tunica albuginea (curved black arrows). Varicocele (asterisk). Lower left and lower right: Images of a testicular tumor. On the proton density image (lower left), the signal intensity from both testicles is similar. On the T2-weighted image (lower right), testicular tumor (asterisk) demonstrates lower signal intensity as compared with the higher signal intensity of the normal testicular tissue (T).
  • Advantages and Disadvantages
  • COMPARISON OF IMAGING METHODS (FIGURES 6-42 THROUGH 6-45)
  • Figure 6-42. Comparison of imaging methods in the evaluation of renal cell carcinoma. Upper left: Computed tomography (CT) scan showing a renal cyst (Cy) in the right kidney. There is bulging (arrow) in the contour of the left kidney (K), but it is difficult to discern if the lesion represents a neoplasm. Upper right: Angiogram showing small vascular lesions in the inferior pole of the left kidney (arrows). Lower left and lower right: MRI scans. Lower left: T1-weighted noncontrast scan. Lower right: T1-weighted postcontrast scan. The renal cyst (Cy) in the right kidney does not show any enhancement. The lesion (arrow) in the left kidney (K) shows marked enhancement, indicating that it is solid in nature. In this example, the contrast-enhanced MRI is superior to CT in the detection and characterization of the left renal mass.
  • Figure 6-43. Comparison of imaging methods: metastatic extra-adrenal familial pheochromocytoma. 10-year-old boy with hypertension and seizures precipitated by abdominal palpation. Family history of multiple extra-adrenal pheochromocytomas in the mother. Upper left: Excretory urogram. The right ureter is dilated and elevated (curved arrow), with the right posterior portion of the bladder displaced toward the left (straight arrow). The urographic diagnosis is possible extra-adrenal paravesical pheochromocytoma. Upper right: Right femoral arteriogram. Tumor stain (arrow) in right paravesical location. The angiographic diagnosis is extra-adrenal paravesical pheochromocytoma. Lower left: Computed tomography (CT) scan. Transverse tomogram through bladder (B) shows the tumor (T) indenting the bladder (arrows). R = rectum. Lower right: CT scan. Transverse tomogram through bladder. Recurrence of symptoms following removal of the right paravesical pheochromocytoma prompted another CT study, which shows recurrent tumor (arrow) in the bladder wall. Each imaging study complemented or supplemented the previous one. None, however, diagnosed the small liver metastases discovered at surgery.
  • Figure 6-44. Comparison of imaging methods. Upper left is an example of a nonenhanced computed tomography (CT), and upper right is an ultrasound study in the demonstration of renal calcifications. Fine calcifications in the medullary region indicate medullary nephrocalcinosis. They are of high density on CT (arrows) and are shown as echogenic foci (arrows) on an ultrasound scan. Lower left and lower right: Example of images of a transitional cell carcinoma and the calcified renal cyst. Retrograde urogram (lower left) shows filling defects due to tumor in the renal pelvis (black arrow) at ureteropelvic junction, and also seen are the calcifications in a lower pole mass (white arrows). Note that the infundibulum and calices of the lower pole failed to opacify in this 45-year-old woman with hematuria. On the CT scan (lower right) the cystic nature of the calcified renal mass (curved arrow) is well demonstrated and the CT scan shows better the extent of the tumor (T), which involves the entire lower pole of the kidney and extends into the dilated renal pelvis.
  • Figure 6-45. Comparison of imaging methods. Upper left and upper right: Renal sarcoma with vascular invasion. Axial CT (upper left) reveals a left renal mass (arrow). The visualized left renal vein is invaded and expanded with thrombus (asterisk). On this sagittal ultrasound Doppler image (upper right) in the same patient, the thrombus extends across the midline from the left renal vein into the inferior vena cava (IVC) (asterisk). Lower left and lower right: Demonstration of an arterial venous malformation to the seminal vesicles. On the CT scan (lower left), the right seminal vesicle (SV) is enlarged, but the nature of the enlargement (arrow) is difficult to discern. On a magnetic resonance imaging (MRI) scan (lower right), the enlarged vessels (arrows) are demonstrated as the flowing blood within the vessel, lack signal intensity in contrast to the medium signal intensity of the seminal vesicles (SV). Urinary bladder (B).
  • Bibliography
  • Contrast Agents
  • Radiography
  • Ultrasound
  • Computed Tomography Scanning
  • Magnetic Resonance Imaging
  • Comparison of Imaging Methods
  • 7 Vascular Interventional Radiology*
  • TRANSCATHETER EMBOLIZATION
  • Renal AVFs and Malformations
  • Bleeding Sites
  • Figure 7-1. Transcatheter embolization of a large arteriovenous malformation (AVM) in a 64-year-old woman with hematuria. A: A conventional film midstream aortogram. An enlarged left renal artery is seen. There is a large serpiginous AVM arising from the lower pole renal artery branch with aneurysmal dilatation of the draining renal vein. B: Selective left renal digital subtraction arteriogram (DSA) after coil embolization shows cessation of flow in the AVM. Coils have been placed in the terminal portion of the lower pole artery and within the AVM. Embolization resulted in resolution of the hematuria.
  • Figure 7-2. Transcatheter embolization of a postbiopsy arteriovenous fistula (AVF) in a 14-year-old boy with hypertension and prior renal transplantation. A bruit was heard on examination. A: Pelvic arteriogram (DSA) shows an AVF arising from a lower pole branch artery. There is aneurysmal dilatation of the draining vein. B: DSA shows that the renal artery has been selectively catheterized, and a 3F coaxial catheter is positioned peripherally within the lower pole branch artery supplying the AVF. Several microcoils have been placed (arrow) and no flow is seen in the AVF. C: Completion DSA of the main renal artery shows absent flow in the AVF (arrow) with minimal devascularization of lower pole parenchyma (curved arrow).
  • Tumors
  • A. Renal Cell Carcinoma
  • B. Angiomyolipoma
  • Figure 7-3. Preoperative embolization of a large right renal cell carcinoma (RCC) in a 28-year-old woman. A: Digital subtraction arteriogram (DSA) of the right renal artery shows a large hypervascular mass involving most of the right kidney. There is tumor thrombus within the renal vein. B: Completion DSA of the right renal artery after Gelfoam embolization shows complete cessation of flow within the tumor and kidney. Contrast is seen within the main renal artery only.
  • Ablation of Renal Function
  • Embolization of Primary Varicocele
  • Embolization of Ovarian Vein Varices (Pelvic Congestion Syndrome)
  • Treatment of High-Flow Priapism
  • RENAL ARTERY ANGIOPLASTY AND STENTING
  • Figure 7-4. Embolization of ovarian vein varices in a 30-year-old multiparous woman with pelvic congestion syndrome. She complained of increasing pelvic pain and dyspareunia. On examination there were prominent vulval varicosities. A: Transjugular right ovarian venography demonstrates multiple large ovarian vein varices. B: Radiograph taken after coil embolization of both ovarian veins and tributaries of the internal iliac veins. The varices have been occluded. The patient's symptoms resolved after the procedure.
  • Figure 7-5. A 17-year-old male had normal erectile function before a skateboard straddle injury. He had a painless partial erection for 13 months and was unable to achieve full erection for intercourse. A: A right internal iliac arteriogram shows a cavernosal arteriosinusoidal fistula arising from the internal pudendal artery (arrow). B: Repeat angiography after selective microcoil embolization for the fistula shows occlusion of the fistula (arrow). After the procedure there was complete detumescence, with return of normal sexual function over the next 3 months.
  • Figure 7-6. Renal artery stenting in an 80-year-old woman with labile hypertension and right renal artery stenosis due to atherosclerotic vascular disease. Her hypertension was poorly controlled on three antihypertensive medications. A: A midstream aortogram at the level of the renal arteries demonstrates a high-grade ostial right renal artery stenosis. B: Repeat midstream aortogram after placement of a 20-mm-long Palmaz stent, dilated to 6 mm. A widely patent renal artery is seen. The stent protrudes slightly into the aortic lumen. The patient's hypertension improved after the procedure.
  • OTHER ENDOVASCULAR PROCEDURES
  • Catheter-Based Renal Sympathetic Denervation for Treatment of Resistant Hypertension
  • Renal Artery Aneurysms
  • CATHETER-DIRECTED FIBRINOLYSIS
  • BIBLIOGRAPHY
  • 8 Percutaneous Endourology & Ureterorenoscopy
  • IMAGING AND PUNCTURE TECHNIQUES
  • Table 8-1. Indications for percutaneous puncture of the renal collecting system.
  • Figure 8-1. Renal ultrasound. A: The longitudinal axis of the kidney forms a 30° angle with the midline. B: The transverse axis of the kidney forms a 45° angle with both a horizontal and a vertical line.
  • Figure 8-2. Universal nephrostomy set (Bard-Angiomed), containing (1) coaxial 17.5-gauge needle with obturator/6F plastic sheath; (2) fine needle (22 gauge); (3) 0.035-in stiff guidewire with floppy J-tip (Lunderquist); (4) coaxial 10F dilator/12F introducer sheath system; and (5) 10F pigtail nephrostomy catheter.
  • Figure 8-3. Ultrasonically guided puncture of a dorsal lower calyx. Needle must be in the scanning plane to be visualized.
  • Figure 8-4. Percutaneous puncture techniques. A: Ultrasonically guided technique: puncture with a 16- to 18-gauge coaxial needle/plastic sheath system. B: Fluoroscopically guided technique: coaxial fine-needle puncture through a larger needle/sheath system.
  • ANTEGRADE PYELOGRAPHY AND PRESSURE/PERFUSION STUDIES
  • Figure 8-5. Whitaker test in a dilated upper tract after vesicoureteral reimplantation (prune belly syndrome). Antegrade perfusion with 10 mL/min results in a vesicopelvic pressure gradient of 10 cm of water, with unobstructed flow.
  • PERCUTANEOUS CATHETER PLACEMENT
  • Figure 8-6. Small-bore tract dilation and nephrostomy catheter insertion. A: J-guidewire inserted through the needle-sheath system and advanced with assistance of the plastic sheath into the renal pelvis. B: Insertion of a coaxial dilator/introducer sheath system over the guidewire. Stiff proximal section of the Lunderquist guidewire prevents extrarenal kinking. C: After the dilator has entered the collecting system, the introducer sheath is advanced over its tip. D: Pigtail nephrostomy catheter is inserted into the renal pelvis over the guidewire and through the introducer sheath.
  • ENDOSCOPIC INTRARENAL INSTRUMENTATION
  • Figure 8-7. Rigid nephroscopes. Left: Continuous-flow sheath telescopes with offset eyepieces for central access to a straight working channel. Right: Graspers and forceps for percutaneous endoscopic stone extraction.
  • Figure 8-8. Large-bore tract dilation for nephroscopy. Left: Insertion of the central catheter of the Alken dilator system over a working wire through the introducer sheath (see also Figure 8-6). An introducer sheath allows parallel insertion of a safety wire into the collecting system. Right: Alken coaxial metal dilators for sequential tract dilation without loss of tract compression. Final step is coaxial insertion of a plastic working sheath or the metal nephroscope sheath.
  • Figure 8-9. Stone in upper caliceal diverticulum requiring percutaneous nephrolithotomy. Left: Plain abdominal radiograph. Right: Intravenous pyelogram.
  • Renal Stones
  • Figure 8-10. Staghorn stone requiring combined percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy. Left: Plain abdominal radiograph. Right: Intravenous pyelogram.
  • Ureteropelvic Stenosis
  • Renal Pelvis Tumor
  • PERCUTANEOUS ASPIRATION AND BIOPSY
  • Table 8-2. Indications for puncture of renal and retroperitoneal lesions.
  • Table 8-3. Differential diagnosis of renal and retroperitoneal lesions.
  • Renal Cysts
  • Retroperitoneal Fluid Collections
  • Figure 8-11. Percutaneous drainage of a lymphocele causing ureteral displacement and compression.
  • Renal and Retroperitoneal Tumors
  • Figure 8-12. Percutaneous fine-needle biopsy. Left: Aspiration biopsy of a renal lesion. Right: Guidance with computed tomography scanning for fine-needle aspiration biopsy of an exophytic renal cell carcinoma.
  • Renal Biopsy
  • URETERORENOSCOPY
  • Table 8-4. Indications for ureterorenoscopy.
  • Figure 8-13. Ureterorenoscopes: 8F telescopes with center and offset eyepieces. 7.5F flexible ureteroscope with 270° tip deflection.
  • Diagnostic Ureterorenoscopy
  • Ureteral Stones
  • Figure 8-14. Ureteral dilation with balloon catheter before ureterorenoscopic removal of a distal ureteral stone (arrow).
  • Figure 8-15. Ureterorenoscopy. A: Straightforward advancement of the instrument over a thin ureteral catheter or guidewire can catch the mucosa of the orifice. B: With 180° upside-down rotation of the instrument, the ureteral catheter holds the orifice open like a tent.
  • Ureteropelvic Stenosis
  • Ureteral Strictures
  • Ureteral Tumors
  • Figure 8-16. Intravenous pyelogram revealing a fibroepithelioma in the midleft ureter (arrow) without urinary obstruction.
  • BIBLIOGRAPHY
  • Percutaneous Catheter Placement
  • Antegrade Pyelography and Pressure/Perfusion Studies
  • Percutaneous Renal Stone Treatment
  • Percutaneous Endoscopic Surgery
  • Percutaneous Aspiration and Biopsy
  • Stone Basketing, Ureterorenoscopy
  • 9 Laparoscopic Surgery
  • PHYSIOLOGY OF LAPAROSCOPY
  • Physiology: Cardiovascular
  • Physiological Complications: Cardiovascular
  • Physiology: Pulmonary, Acid-Base, and Insufflant Related
  • Figure 9-1. Reduction of venous return and cardiac output during laparoscopy. (Borrowed with permission from Wolf JS Jr, Stoller ML: The physiology of laparoscopy: Basic principles, complications, and other considerations. J Urol 1994; 152:294.)
  • Physiological Complications: Pulmonary, Acid-Base, and Insufflant Related
  • SELECTION OF LAPAROSCOPIC APPROACH
  • Transperitoneal Versus Retroperitoneal
  • Hand Assistance
  • Figure 9-2. Surgeon's hand inside Gelport. (Applied Medical, Rancho Santa Margarita, CA.)
  • Robotic Assistance
  • LAPAROSCOPIC INSTRUMENTATION AND BASIC TECHNIQUES
  • Preoperative Preparation
  • Entry: Obtaining Pneumoperitoneum
  • Figure 9-3. da Vinci Surgical System. (Intuitive Surgical, Sunnyvale, CA.)
  • Figure 9-4. Preperitoneal location of the tip of Veress needle.
  • Figure 9-5. Hasson cannula.
  • Entry: Port Placement
  • Figure 9-6. Self-retaining port. (AutoSuture Co, Norwalk, CT.)
  • Figure 9-7. Insertion of port with shielded sharp tip. A blunt shield moves forward to shield the blade once resistance decreases. (AutoSuture Co, Norwalk, CT.)
  • Entry: Extraperitoneal Approach
  • Figure 9-8. Nonbladed trocar, with clear plastic tip that allows visualization as the abdominal wall is penetrated. (Ethicon Endo-Surgery, Cincinnati, OH.)
  • Figure 9-9. Step system port. (AutoSuture Co, Norwalk, CT.)
  • Figure 9-10. Preperitoneal distention balloon. (Auto-Suture Co, Norwalk, CT.)
  • Laparoscopic Video Instrumentation and Cart
  • Laparoscopic Instrumentation
  • Exiting the Abdomen
  • Figure 9-11. Carter-Thomason device (Inlet Medical Inc., Eden Prairie, MN). A: Needle point-suture passer. B: Fascial closure guide.
  • Postoperative Care
  • SPECIFIC PROCEDURES
  • Pelvic Lymph Node Dissection
  • Figure 9-12. Balloon device inflated in the preperitoneal space for extraperitoneal laparoscopic pelvic lymph node dissection.
  • Varicocelectomy
  • Orchidopexy
  • Figure 9-13. Port placements for laparoscopic pelvic lymph node dissection. A: Diamond configuration typically used. B: Fan configuration for use in obese patients.
  • Renal Cyst Decortication
  • Simple and Radical Nephrectomy
  • Figure 9-14. Key landmarks for laparoscopic pelvic lymph node dissection are the obliterated umbilical ligament, gonadal vessels, and internal inguinal ring.
  • Figure 9-15. Dashed lines indicate incisions into posterior peritoneum for orchidopexy of a left intra-abdominal testis.
  • Figure 9-16. One of the possible port configurations for right transperitoneal laparoscopic nephrectomy.
  • Figure 9-17. One of the possible port configurations for left retroperitoneal laparoscopic nephrectomy.
  • Nephroureterectomy
  • Figure 9-18. Transvesical dissection of the distal ureter performed with a Colling's knife on a resectoscope placed through a 10-mm port inserted suprapubically into the bladder. After the nephrectomy portion of the procedure and clipping of the ureter, incision (dotted black line) is gradually made around the ureteral orifice (white arrowhead) until the distal ureter can be pulled free of the bladder.
  • Partial Nephrectomy and Renal Mass Ablation
  • Figure 9-19. Partial nephrectomy. Tumor (black asterisk) is being elevated by a grasper (entering from top of figure), as it is excised with scissors. An irrigator-aspirator depresses the tumor bed and helps maintain visualization. The peripheral resection margin is indicated with the white line.
  • Donor Nephrectomy
  • Pyeloplasty
  • Figure 9-20. Ureteropelvic junction obstruction of left kidney associated with crossing vessel (white line) before laparoscopic pyeloplasty. Renal pelvis is marked with white asterisk and ureter is indicated by a black asterisk.
  • Adrenalectomy
  • Figure 9-21. One of the possible port configurations for right transperitoneal laparoscopic adrenalectomy.
  • Retroperitoneal Lymph Node Dissection
  • Figure 9-22. Left-sided laparoscopic retroperitoneal lymph node dissection. Black line indicates aorta and white lines indicate renal and gonadal veins.
  • Radical Prostatectomy
  • Radical Cystectomy with Urinary Diversion
  • Miscellaneous Laparoscopic Procedures
  • COMPLICATIONS
  • FUTURE OF LAPAROSCOPY
  • BIBLIOGRAPHY
  • 10 Robotic Surgery in Urology
  • BACKGROUND
  • History
  • da Vinci System
  • Figure 10-1. The da Vinci Si robotic surgical system made by Intuitive Surgical Inc. It consists of the (A) surgeon console (here with the dual console HD Si) and (B) patient-side surgical cart, in this model with four arms (Images courtesy of Intuitive Surgical Inc.).
  • Figure 10-2. Example of the (A) EndoWrist technology, with seven degrees of freedom at the tip of the instrument and (B) surgeon's hand control at the console.
  • LOWER URINARY TRACT OPERATIONS
  • Radical Prostatectomy
  • Table 10-1. Perioperative and oncologic outcomes of robotic-assisted laparoscopic radical prostatectomy from select published series.
  • Table 10-2. Urinary outcomes after robotic-assisted laparoscopic radical prostatectomy from select series.
  • Radical Cystectomy
  • Table 10-3. Sexual function outcomes after robotic-assisted laparoscopic radical prostatectomy from select series.
  • Table 10-4. Reported complications after robotic-assisted laparoscopic radical prostatectomy from select series.
  • UPPER URINARY TRACT OPERATIONS
  • Pyeloplasty
  • Partial Nephrectomy
  • PEDIATRIC OPERATIONS
  • SINGLE-SITE ROBOTIC SURGERY
  • COST-EFFECTIVENESS
  • TRAINING IN ROBOTICS
  • BIBLIOGRAPHY
  • Radical Prostatectomy
  • Radical Cystectomy
  • Pyeloplasty
  • Partial Nephrectomy
  • Pediatric Operations
  • Single-Site Robotic Surgery
  • Cost-Effectiveness
  • Training in Robotics
  • 11 Retrograde Instrumentation of the Urinary Tract
  • URETHRAL CATHETERIZATION
  • Technique of Catheterization
  • A. In Men
  • B. In Women
  • C. Difficult Placement and Removal
  • Catheter Design
  • URETHROSCOPY
  • Figure 11-1. Urethral catheters, metal stylet, catheter, and guidewire techniques for catheter insertion.
  • CYSTOSCOPY
  • URETERAL CATHETERIZATION
  • Figure 11-2. Brushing of a proximal ureteral lesion. A: Insertion of the brush covered by a catheter. B: Advancement of the brush through the lesion.
  • Figure 11-3. Loops, wire baskets, and wire baskets with balloon catheters for extraction of ureteral stones.
  • Figure 11-4. Ureteral catheters and self-retaining internal stents.
  • Figure 11-5. Negotiating a difficult ureteral orifice. A: Guidewire engaged in orifice cannot be advanced. B: Endoscope is rotated toward contralateral orifice. Guidewire remains engaged in orifice. C: Guidewire is advanced against bladder wall. D: Guidewire negotiated beyond angulation.
  • TRANSURETHRAL SURGERY
  • Figure 11-6. Transurethral resectoscope. Left: Continuous-flow sheath, standard sheath, working element with cutting loop, telescope. Right: Instrument assembled.
  • Figure 11-7. Urethral probes and sounds.
  • LOWER TRACT CALCULI
  • ADVANCED INSTRUMENTATION
  • Lasers
  • Figure 11-8. Multifocal bladder cancer. Left: Transurethral ultrasound. Right: Cystectomy specimen.
  • Ultrasonography
  • BIBLIOGRAPHY
  • Urethral Catheterization
  • Transrectal and Transurethral Ultrasound
  • Stone Basketing
  • Cytology, Biopsy Histology
  • Endoscopy
  • Lithotripsy
  • 12 Urinary Obstruction & Stasis
  • Classification
  • Etiology
  • A. Congenital
  • B. Acquired
  • Pathogenesis and Pathology
  • A. Lower Tract (eg, Urethral Stricture)
  • B. Midtract (eg, Prostatic Hyperplasia)
  • Figure 12-1. Changes in the bladder developing from obstruction. Upper left: Normal bladder and prostate. Upper right: Obstructing prostate causing trabeculation, cellule formation, and hypertrophy of the interureteric ridge. Bottom: Marked trabeculation (hypertrophy) of the vesical musculature; diverticulum displacing left ureter.
  • C. Upper Tract
  • Figure 12-2. Mechanisms and results of obstruction. Upper left: Early stage. Elongation and dilatation of ureter due to mild obstruction. Upper center: Later stage. Further dilatation and elongation with kinking of the ureter; fibrous bands cause further kinking. Upper right: Intrarenal pelvis. Obstruction transmits all back pressure to parenchyma. Lower: Extrarenal pelvis, when obstructed, allows some of the increased pressure to be dissipated by the pelvis.
  • Figure 12-3. Pathogenesis of bilateral hydronephrosis. Progressive changes in bladder, ureters, and kidneys from obstruction of an enlarged prostate: thickening of bladder wall, dilatation and elongation of ureters, and hydronephrosis.
  • Figure 12-4. Hydronephrotic left renal pelvis. Low-density mass (P) in left renal sinus had attenuation value similar to that of water, suggesting the correct diagnosis. Unless intravenous contrast material is used, differentiation from peripelvic cyst may be difficult.
  • Figure 12-5. Lower right ureteral obstruction. Mild-to-moderate dilatation of the collecting system with rounded blunting of the calyces.
  • Figure 12-6. Pathogenesis of unilateral hydronephrosis. Progressive changes in ureter and kidney secondary to obstructing calculus (arrowheads). As the right kidney undergoes gradual destruction, the left kidney gradually enlarges (compensatory hypertrophy).
  • Physiologic Explanation of Symptoms of Bladder Neck Obstruction
  • A. Compensation Phase
  • B. Decompensation Phase
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Urinary Tract Imaging (Figure 12-7)
  • Figure 12-7. Changes in bladder, ureters, and kidneys caused by obstruction. Upper left: Cystogram showing benign prostatic enlargement and multiple diverticula. Arrows point to femoral hernia that probably developed as a result of straining to urinate. Upper right: Pregnancy. Significant dilatation and elongation of upper right ureter due to compression at the pelvic line. Left side normal. Lower left: Excretory urogram, 70 minutes after injection. Advanced right hydronephrosis secondary to ureteropelvic obstruction. Mild ureteropelvic obstruction on left. Lower right: Stone in left ureter (at arrow) with mild hydronephrosis.
  • E. Isotope Scanning (Nuclear Renography)
  • F. Instrumental Examination
  • Differential Diagnosis
  • Complications
  • Treatment
  • A. Relief of Obstruction
  • B. Eradication of Infection
  • Prognosis
  • BIBLIOGRAPHY
  • 13 Vesicoureteral Reflux
  • ANATOMY OF THE URETEROVESICAL JUNCTION
  • Mesodermal Components
  • A. The Ureter and the Superficial Trigone
  • B. Waldeyer's Sheath and the Deep Trigone
  • Endodermal Component
  • A. Internal Longitudinal Layer
  • B. Middle Circular Layer
  • C. Outer Longitudinal Layer
  • Figure 13-1. Normal ureterotrigonal complex. A: Side view of ureterovesical junction. Waldeyer's muscular sheath invests the juxtavesical ureter and continues downward as the deep trigone, which extends to the bladder neck. The ureteral musculature becomes the superficial trigone, which extends to the verumontanum in the male and stops just short of the external meatus in the female. B: Waldeyer's sheath is connected by a few fibers to the detrusor muscle in the ureteral hiatus. This muscular sheath, inferior to the ureteral orifices, becomes the deep trigone. The musculature of the ureters continues downward as the superficial trigone. (Redrawn and modified, with permission, from Tanagho EA, Pugh RCB: The anatomy and function of the ureterovesical junction. Br J Urol 1963;35:151.)
  • PHYSIOLOGY OF THE URETEROVESICAL JUNCTION
  • Figure 13-2. Histology of the trigone in primary reflux. Top: Normal trigone demonstrating wealth of closely packed smooth-muscle fibers. Bottom: The congenitally attenuated trigonal muscle that accompanies vesicoureteral reflux. Note the absence of inflammatory cell. (Reproduced, with permission, from Tanagho EA et al: Primary vesicoureteral reflux: Experimental studies of its etiology. J Urol 1965;93:165.)
  • VESICOURETERAL REFLUX
  • CAUSES
  • Congenital Causes
  • A. Trigonal Weakness (Primary Reflux)
  • B. Familial Reflux
  • Figure 13-3. A: Small ureterocele developing in a duplicated system (where it always involves a lower ureteral orifice). B: Expansion of submucosal segment leads to lifting and angulation of ipsilateral lower pole ureteral orifice. Duplicated system ureteroceles are rarely so small. (Diagrammatic representation.) (Reproduced, with permission, from Tanagho EA: Ureteroceles: Embryogenesis, pathogenesis and management. J Cont Educ Urol 1979;18:13.)
  • C. Ureteral Abnormalities
  • Voiding Dysfunction
  • Vesical Trabeculation
  • Edema of the Vesical Wall Secondary to Cystitis
  • Figure 13-4. Histology of the various grades of submucosal muscular weakness of the ureteral orifice. (See also Figure 13-9.) A: Normal. Minimal deficiency. (Cone orifice.) B: More marked muscular weakness. (Stadium orifice.) C: Marked muscular deficiency. (Horseshoe orifice.) D: Extreme muscular deficiency. Only a few muscle fibers can be seen; the rest is collagen tissue.
  • Eagle-Barrett (Prune Belly) Syndrome
  • Iatrogenic Causes
  • Figure 13-5. Ureteral duplication and ureterocele as causes of vesicoureteral reflux. A: Ureteral duplication showing juxtavesical and intravesical ureters encased in common sheath (Waldeyer's). The superior ureter, which always drains the lower renal pole, has a shorter intravesical segment; in addition, it is somewhat devoid of muscle. It therefore tends to allow reflux. B: Duplication with ureterocele that always involves caudal ureter, which drains upper renal pole. Pinpoint orifice is obstructive, causing hydroureteronephrosis. Resulting wide dilatation of ureter and ureteral hiatus shortens the intravesical segment of the other ureter, often causing it to reflux. C: Resection of ureterocele allows reflux into that ureter.
  • A. Prostatectomy
  • Figure 13-6. Development of ureteral saccule, seen occasionally in cases of primary reflux but more commonly in obstructed or neurogenic bladders with marked trabeculation. Note that the vesical mucosa herniates through the ureteral hiatus, pulling the ureteral orifice upward with it. The orifice may ultimately open in the saccule rather than in the bladder.
  • B. Wedge Resection of the Posterior Vesical Neck
  • C. Ureteral Meatotomy
  • D. Resection of Ureterocele
  • Contracted Bladder
  • COMPLICATIONS
  • Pyelonephritis
  • Hydroureteronephrosis (See also Chapter 12)
  • INCIDENCE
  • Figure 13-7. Excretory urogram with changes that imply right vesicoureteral reflux. Upper left: Excretory urogram showing normal right urogram and a ureter that is mildly dilated and remains full through its entire length. The ureteral change implies reflux. Upper right: Cystogram demonstrates the reflux. Note, now, the degree of dilatation of the ureter, pelvis, and calyces. Lower left: Excretory urogram shows bilateral hydroureteronephrosis with pyelonephritic scarring. These findings imply the presence of reflux. Lower right: Voiding cystourethrogram. Free reflux bilaterally.
  • CLINICAL FINDINGS
  • Figure 13-8. Cystograms revealing vesicoureteral reflux. Upper left: Saccule at right ureterovesical junction. Upper right: Meningomyelocele. Reflux with severe bilateral hydroureteronephrosis; serum creatinine, 0.6 mg/dL; phenolsulfonphthalein excretion, 5% in 1 hour. Lower left: Postprostatectomy patient with reflux on left and bilateral saccules. Lower right: Ten-year-old boy with meningomyelocele. Bladder has been emptied. Impairment of drainage at ureterovesical junctions is demonstrated. (Courtesy of Hutch JA, Amar AD: Vesicoureteral Reflux and Pyelonephritis. Appleton-Century-Crofts, 1972.)
  • Symptoms Related to Reflux
  • A. Symptomatic Pyelonephritis
  • B. Asymptomatic Pyelonephritis
  • C. Symptoms of Cystitis Only
  • D. Renal Pain on Voiding
  • E. Uremia
  • F. Hypertension
  • Symptoms Related to the Underlying Disease
  • A. Urinary Tract Obstruction
  • B. Spinal Cord Disease
  • Physical Findings
  • Laboratory Findings
  • X-Ray Findings
  • Instrumental Examination
  • A. Cystoscopy
  • Figure 13-9. Cystoscopic appearance of the normal ureteral orifice and 3° of incompetence of the ureterovesical junction. (See also Figure 13-4.) (Reproduced, with permission, from Lyon RP et al: The ureteral orifice: Its configuration and competency. J Urol 1969;102:504.)
  • DIFFERENTIAL DIAGNOSIS
  • TREATMENT
  • Medical Treatment
  • A. Indications
  • B. Methods of Treatment
  • C. Evaluation of Success of Medical Treatment
  • Surgical Treatment
  • A. Indications
  • B. Types of Surgical Treatment
  • C. Subureteric Transurethral Injection (STING)
  • PROGNOSIS
  • BIBLIOGRAPHY
  • 14 Bacterial Infections of the Genitourinary Tract
  • EPIDEMIOLOGY
  • PATHOGENESIS
  • Bacterial Entry
  • Table 14-1. Epidemiology of UTI by age, group, and sex.
  • Host Defenses
  • Bacterial Pathogenic Factors
  • CAUSATIVE PATHOGENS
  • DIAGNOSIS
  • Urinalysis
  • Table 14-2. Sensitivity and specificity of urinalysis.
  • Urine Culture
  • Localization Studies
  • Table 14-3. Probability of UTIs based upon urine culture.
  • Figure 14-1. Localization of lower urinary tract infection. A positive culture in the voided bladder urine specimen VB1 suggests infection of the urethra, while in VB2, an infection of the bladder, and in EPS or VB3, an infection of the prostate.
  • ANTIBIOTICS
  • Table 14-4. Antibiotics that require dosage adjustments for liver and renal diseases.
  • Trimethoprim-Sulfamethoxazole
  • Table 14-5. Recommended antimicrobial agents for common genitourinary pathogens.
  • Fluoroquinolones
  • Nitrofurantoin
  • Table 14-6. Recommended antimicrobial agents and duration of therapy based upon the type of UTI.
  • Table 14-7. Prophylactic antibiotics regimen.
  • Aminoglycosides
  • Cephalosporins
  • Penicillins
  • Antibiotic Resistance
  • Probiotics
  • CLINICAL PRESENTATION
  • KIDNEY INFECTION
  • Acute Pyelonephritis
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • C. Management
  • Figure 14-2. Acute pyelonephritis. Computed tomography scan with intravenous contrast demonstrates a perfusion defect (white arrow) and enlargement of the affected kidney.
  • Emphysematous Pyelonephritis
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • C. Management
  • Chronic Pyelonephritis
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • Figure 14-3. Chronic pyelonephritis. Multiple parenchymal defects (white and black arrows) are seen on DMSA scan (A)), suggestive of scarring from recurrent infection. Voiding cystourethrogram (B) revealed high-grade reflux in this patient.
  • C. Management
  • Renal Abscesses
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • Figure 14-4. Renal abscess. CT scan with intravenous contrast demonstrates a large perinephric fluid collection with rim enhancement (white arrow). The parenchyma defect in the right kidney is suggestive of pyelonephritis.
  • C. Management
  • Xanthogranulomatous Pyelonephritis
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • C. Management
  • Pyonephrosis
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • C. Management
  • BLADDER INFECTION
  • Acute Cystitis
  • Figure 14-5. Xanthogranulomatous pyelonephritis. A: CT scan demonstrates a large heterogeneous left kidney, with dilated calyces and areas filled with lipid-laden macrophages. Xanthogranulomatous pyelonephritis is often associated with the presence of renal stones. B: Pathology specimen better demonstrated the pockets of intraparenchymal abscesses and deposition of macrophages (arrows). PNS, percutaneous nephrostomy.
  • Figure 14-6. Pyonephrosis. Ultrasonography demonstrates fluid-debris level (white arrow) within the dilated renal pelvis.
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • C. Management
  • Recurrent Cystitis/UTI
  • A. Presentation and Findings
  • B. Radiographic Imaging
  • C. Management
  • Malakoplakia
  • A. Presentation and Findings
  • B. Radiologic Imaging
  • C. Management
  • PROSTATE INFECTION
  • Acute Bacterial Prostatitis
  • A. Presentation and Findings
  • B. Radiologic Imaging
  • C. Management
  • Chronic Bacterial Prostatitis
  • A. Presentation and Findings
  • Table 14-8. Technique of localization cultures (four-cup test) for the diagnosis of prostatitis.
  • B. Radiologic Imaging
  • C. Management
  • Granulomatous Prostatitis
  • A. Presentation and Findings
  • B. Management
  • Prostate Abscess
  • A. Presentation and Findings
  • Figure 14-7. Prostatic abscess. Transrectal ultrasonography demonstrates hypoechoic lesions (black and white arrows) in the prostate consistent with abscesses.
  • B. Radiologic Imaging
  • C. Management
  • URETHRITIS
  • Types of Urethritis
  • A. Presentation and Findings
  • B. Radiologic Imaging
  • C. Management
  • EPIDIDYMITIS/ORCHITIS
  • Causes of Epididymitis/Orchitis
  • A. Presentation and Findings
  • B. Radiologic Imaging
  • C. Management
  • SPECIAL CIRCUMSTANCES
  • UTI Related to Pregnancy
  • Table 14-9. Antibiotics and their effects on pregnancy.
  • UTI in Patients with Human Immunodeficiency Virus or Acquired Immunodeficiency Syndrome
  • A. UTI/Cystitis
  • B. Prostatitis
  • C. Epididymitis and Urethritis
  • D. Infection by Uncommon Organisms
  • UTIs in Patients with Diabetes Mellitus
  • BIBLIOGRAPHY
  • 15 Specific Infections of the Genitourinary Tract
  • TUBERCULOSIS
  • Etiology
  • Pathogenesis (Figure 15-1)
  • A. Kidney and Ureter
  • B. Bladder
  • C. Prostate and Seminal Vesicles
  • D. Epididymis and Testis
  • Figure 15-1. Pathogenesis of tuberculosis of the urinary tract.
  • Pathology
  • A. Kidney and Ureter
  • B. Bladder
  • C. Prostate and Seminal Vesicles
  • D. Spermatic Cord, Epididymis, and Testis
  • E. Female Genital Tract
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings (Figure 15-2)
  • Figure 15-2. Radiologic evidence of tuberculosis. Upper left: Excretory urogram showing "moth-eaten" calyces in upper renal poles. Calcifications in upper calyces; right upper ureter is straight and dilated. Upper right: Excretory urogram showing ulcerated and dilated calyces on the left. Lower left: Abdominal computed tomography (CT) with contrast showing left renal tuberculosis with calcification, poor parenchymal perfusion, and surrounding inflammation. Lower right: Noncontrast abdominal CT showing late effects of renal TB with calyceal dilation, loss of parenchyma, and urothelial calcifications. (CT images courtesy of Fergus Coakley, MD, UCSF Radiology.)
  • E. Cystoscopic Examination
  • Differential Diagnosis
  • Complications
  • A. Renal Tuberculosis
  • B. Ureteral Tuberculosis
  • C. Vesical Tuberculosis
  • D. Genital Tuberculosis
  • Treatment
  • A. Renal Tuberculosis
  • B. Vesical Tuberculosis
  • C. Tuberculosis of the Epididymis
  • D. Tuberculosis of the Prostate and Seminal Vesicles
  • E. General Measures for All Types
  • F. Treatment of Other Complications
  • CANDIDIASIS
  • Table 15-1. Risk factors for fungal UTI.
  • ACTINOMYCOSIS
  • Etiology
  • Clinical Findings
  • Treatment
  • Prognosis
  • SCHISTOSOMIASIS (BILHARZIASIS)
  • Etiology
  • Pathogenesis
  • Pathology
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • E. Cystoscopic Examination
  • Differential Diagnosis
  • Treatment
  • A. Medical Measures
  • Figure 15-3. Schistosomiasis. Plain films. Upper left: Extensive calcification in the wall of a contracted bladder. Right: Extensive calcification of the bladder and both ureters up to the renal pelves. The ureters are dilated and tortuous. Lower left: Extensive calcification of seminal vesicles and ampullae of vasa.
  • B. General Measures
  • Figure 15-4. Schistosomiasis. Upper left: Excretory urogram showing markedly contracted bladder. Lower right ureter dilated probably secondary to vesicoureteral reflux. Right: Excretory urogram at 2 hours showing a fairly normal right kidney. The upper ureter is distorted. Arrows point to calcified wall. The lower ureter is quite abnormal. The calyces and pelvis of the left kidney are dilated, but the kidney shows atrophy secondary to nonspecific infection. The upper ureter is dilated and displaced by elongation due to obstruction. Arrows show calcification. Linear calcification can be seen in the periphery of the lower half of the bladder wall (arrows). Lower left: Nodular squamous cell carcinoma of the bladder. Dilated left lower ureter probably secondary to obstruction by tumor. Nonvisualization of the right ureter caused by complete occlusion.
  • C. Complications
  • Prognosis
  • FILARIASIS
  • Etiology
  • Pathogenesis and Pathology
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Cystoscopy
  • E. X-Ray Findings
  • Prevention
  • Treatment
  • A. Specific Measures
  • B. General Measures
  • C. Surgical Measures
  • D. Treatment of Chyluria
  • Prognosis
  • ECHINOCOCCOSIS (HYDATID DISEASE)
  • Etiology
  • Clinical Findings
  • Figure 15-5. Hydatid disease, right kidney. Plain film showing two calcified hydatid cysts.
  • Treatment
  • Prognosis
  • BIBLIOGRAPHY
  • Tuberculosis
  • Candidiasis
  • Actinomycosis
  • Schistosomiasis (Bilharziasis)
  • Filariasis
  • Onchocerciasis
  • Echinococcosis (Hydatid Disease)
  • 16 Sexually Transmitted Diseases
  • URETHRITIS AND CERVICITIS
  • Urethritis in Men
  • A. Etiology
  • Table 16-1. Sexually transmitted disease (STD) syndromes.a
  • B. Document Urethritis
  • C. Treatment of Gonococcal Infections
  • Table 16-2. Urethritis, cervicitis, and related infections: recommended treatment regimens.a
  • D. Treatment of Nongonococcal Urethritis
  • E. Treatment of Recurrent and Persistent Urethritis
  • Mucopurulent Cervicitis in Women
  • EPIDIDYMITIS
  • Table 16-3. Epididymitis: recommended treatment regimens.a
  • GENITAL ULCER DISEASES
  • Genital Herpes Simplex Virus Infection
  • Syphilis
  • Table 16-4. Genital ulcers: recommended treatment regimens.a
  • Chancroid
  • Lymphogranuloma Venereum
  • Granuloma Inguinale (Donovanosis)
  • Genital Warts
  • Table 16-5. External genital warts: Recommended treatment regimens.a
  • SUBCLINICAL GENITAL HPV INFECTION
  • HIV INFECTION: OVERVIEW OF DETECTION, INITIAL EVALUATION, AND REFERRAL
  • Testing for HIV
  • Acute Retroviral Syndrome
  • Initial Management of HIV Infection
  • BIBLIOGRAPHY
  • 17 Urinary Stone Disease
  • RENAL AND URETERAL STONES
  • Etiology
  • A. Crystal Component
  • B. Matrix Component
  • Figure 17-1. Gross picture of matrix calculus percutaneously extracted after extracorporeal shock wave lithotripsy failure.
  • Urinary Ions
  • A. Calcium
  • B. Oxalate
  • C. Phosphate
  • D. Uric Acid
  • Figure 17-2. Radiolucent right staghorn renal calculus appreciated after percutaneous injection of radiocontrast material. This uric acid stone was effectively removed in a single percutaneous procedure. Postoperative urinary alkalinization has been effective prophylaxis.
  • E. Sodium
  • F. Citrate
  • G. Magnesium
  • H. Sulfate
  • I. Other Urinary Stone Inhibitors
  • Stone Varieties
  • A. Calcium Calculi
  • Figure 17-3. Retrograde pyelogram demonstrating multiple punctate calcifications within the renal parenchyma establishing the diagnosis of nephrocalcinosis. Renal pelvis and infundibula are free of calculi.
  • Figure 17-4. Scout abdominal radiograph demonstrating bilateral, multiple renal calculi in a patient with renal tubular acidosis, type I.
  • B. Noncalcium Calculi
  • Figure 17-5. Scout abdominal radiograph demonstrating large bilateral struvite staghorn calculi. Patient was treated for many years with numerous antibiotics for re-current urinary tract infections. Only after this radiograph were calculi identified and removed and the infections resolved.
  • Figure 17-6. Scout radiograph demonstrating a right cystine calculus. Note ground-glass appearance with smooth edges.
  • Symptoms and Signs at Presentation
  • A. Pain
  • Figure 17-7. Radiation of pain with various types of ureteral stone. Upper left: Ureteropelvic stone. Severe costovertebral angle pain from capsular and pelvic distention; acute renal and urethral pain from hyperperistalsis of smooth muscle of calyces, pelvis, and ureter, with pain radiating along the course of the ureter (and into the testicle, since the nerve supply to the kidney and testis is the same). The testis is hypersensitive. Upper right: Mid ureteral stone. Same as described earlier but with more pain in the lower abdominal quadrant. Left: Low ureteral stone. Same as described earlier, with pain radiating into bladder, vulva, or scrotum. The scrotal wall is hyperesthetic. Testicular sensitivity is absent. When the stone approaches the bladder, urgency and frequency with burning on urination develop as a result of inflammation of the bladder wall around the ureteral orifice.
  • B. Hematuria
  • C. Infection
  • Figure 17-8. Bilateral renal calculi seen on scout radiograph with numerous bilateral percutaneous nephrostomy tubes to drain severe bilateral pyonephrosis.
  • D. Associated Fever
  • E. Nausea and Vomiting
  • Special Situations
  • A. Renal Transplantation
  • B. Pregnancy
  • Figure 17-9. Scout abdominal radiograph demonstrating renal calculus in a renal transplant in the right iliac fossa. Note native renal vasculature with marked calcifications secondary to malignant diabetes mellitus.
  • C. Dysmorphia
  • Figure 17-10. Scout radiograph demonstrating left renal calculus with double-J ureteral stent in place. Skeletal fetal structures can be appreciated in this pregnant patient.
  • D. Obesity
  • Figure 17-11. Scout abdominal radiograph demon-strating a right renal calculus (arrow) in a patient with severe kyphoscoliosis. Respiratory compromise limited patient positioning for surgery.
  • E. Medullary Sponge Kidney
  • F. Renal Tubular Acidosis
  • G. Associated Tumors
  • H. Pediatric Patients
  • I. Caliceal Diverticula
  • Figure 17-12. Intravenous pyelogram demonstrating symptomatic right calyceal diverticula with numerous small calculi.
  • J. Renal Malformations
  • Figure 17-13. Scout abdominal radiograph demonstrating horseshoe kidney with lateral ureteral deviation and double-J ureteral stent. Extraosseous calcifications are left lower calyceal stones.
  • Evaluation
  • A. Differential Diagnosis
  • B. History
  • C. Risk Factors
  • D. Physical Examination
  • E. Radiologic Investigations
  • Figure 17-14. Scout abdominal radiograph demonstrating large extraosseous calcification that represents a uterine fibroid. This easily could be confused with a large bladder calculus.
  • Intervention
  • A. Conservative Observation
  • B. Dissolution Agents
  • C. Relief of Obstruction
  • D. Extracorporeal Shock Wave Lithotripsy
  • Figure 17-15. A: Scout abdominal radiograph demonstrating large left staghorn renal calculus. B: Nuclear scintigraphic evaluation of renal calculi. Posterior view demonstrating uptake on large left staghorn calculus after furosemide (Lasix) diuresis. Note right kidney with uptake in lower pole. C: Follow-up tomogram confirms calculus (arrow) in right lower pole missed on initial radiograph.
  • Figure 17-16. Diagrammatic representation of a Dornier HM-3 lithotriptor.
  • Figure 17-17. Shock wave. Vertical axis represents pressure and horizontal axis represents time.
  • Figure 17-18. A: Supersonic shock wave emission from a spark gap electrode. B: Reflecting the shock wave from focus 1 to focus 2 allows for stone fragmentation.
  • Figure 17-19. Piezoceramic finite amplitude emitter. Ceramic components are placed on the concave surface of a sphere and each component is directed to an identified focus.
  • Figure 17-20. Incoming shock waves result in fragmentation from erosion and shattering.
  • E. Ureteroscopic Stone Extraction
  • Figure 17-21. Plain abdominal radiograph demonstrating complete staghorn calculus with the renal pelvic extending into all infundibula and calyces.
  • F. Percutaneous Nephrolithotomy
  • G. Open Stone Surgery
  • H. Other Renal Procedures
  • I. Ureterolithotomy
  • Prevention
  • A. Metabolic Evaluation
  • B. Oral Medications
  • BLADDER STONES
  • Figure 17-22. Genesis and symptoms and signs of vesical calculus.
  • Figure 17-23. A: Plain abdominal radiograph demonstrating two bladder calculi. B: Gross picture of removed bladder calculi. Note the characteristic shape of jackstones typically composed of uric acid.
  • Figure 17-24. A: Scout abdominal radiograph demonstrating extraosseous calcification in the region of the bladder. B: Intravenous pyelogram demonstrates stone to be within a ureterocele.
  • PROSTATIC AND SEMINAL VESICLE STONES
  • URETHRAL AND PREPUTIAL STONES
  • BIBLIOGRAPHY
  • Urinary Ions
  • Calcium
  • Oxalate
  • Uric Acid
  • Cystine
  • Xanthine
  • Triamterene
  • Matrix Urinary Calculi
  • Urinary Stone Inhibitors
  • Citrate
  • Urinary Proteins
  • Trace Elements
  • Renal Tubular Acidosis
  • Water
  • Urinary Stone Disease in Uncommon Situations
  • Spinal Cord Dysfunction
  • Pregnancy
  • Renal Transplantation
  • Obesity
  • Anatomic Renal Anomalies
  • Pediatrics
  • Caliceal Diverticulae
  • Tumors
  • Medical Therapy
  • Surgical Therapy
  • Extracorporeal Shock Wave Lithotripsy
  • Percutaneous Nephrostolithotomy
  • Ureteroscopy
  • 18 Injuries to the Genitourinary Tract
  • EMERGENCY DIAGNOSIS AND MANAGEMENT
  • Special Examinations (Figures 18-1 through 18-3)
  • A. Catheterization and Assessment of Injury
  • Figure 18-1. Algorithm for staging blunt trauma in adults.
  • Figure 18-2. Algorithm for staging penetrating trauma in adults.
  • Figure 18-3. Algorithm for staging blunt trauma in children
  • B. Cystoscopy and Retrograde Urography
  • C. Abdominal Sonography
  • INJURIES TO THE KIDNEY
  • Etiology (Figure 18-4)
  • Figure 18-4. Mechanisms of renal injury. Left: Direct blow to abdomen. Smaller drawing shows force of blow radiating from the renal hilum. Right: Falling on buttocks from a height (contrecoup of kidney). Smaller drawing shows direction of force exerted on the kidney from above. Tear of renal pedicle.
  • Figure 18-5.
  • Pathology and Classification (Figure 18-5)
  • A. Early Pathologic Findings
  • B. Late Pathologic Findings (Figure 18-6)
  • Figure 18-6. Late pathologic findings in renal trauma. Left: Ureteropelvic stenosis with hydronephrosis secondary to fibrosis from extravasation of blood and urine. Right: Atrophy of kidney caused by injury (stenosis) of arterial blood supply.
  • Clinical Findings and Indications for Studies
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Staging and X-Ray Findings
  • Figure 18-7. Computed tomography scan of right kidney following knife stab wound. Laceration with urine extravasation is seen. Large right retroperitoneal hematoma is present.
  • Figure 18-8. Blunt renal trauma to left kidney demonstrating extravasation (at arrow) on intravenous urogram.
  • Figure 18-9. Arteriogram following blunt abdominal trauma shows typical findings of acute renal artery thrombosis (arrow) of left kidney.
  • Differential Diagnosis
  • Complications
  • A. Early Complications
  • B. Late Complications
  • Treatment
  • A. Emergency Measures
  • B. Surgical Measures
  • C. Treatment of Complications
  • Prognosis
  • INJURIES TO THE URETER
  • Etiology
  • Pathogenesis and Pathology
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Imaging Findings
  • Figure 18-10. Stab wound of right ureter shows extravasation (at arrow) on intravenous urogram.
  • E. Ultrasonography
  • F. Radionuclide Scanning
  • Differential Diagnosis
  • Complications
  • Treatment
  • A. Lower Ureteral Injuries
  • B. Midureteral Injuries
  • C. Upper Ureteral Injuries
  • D. Stenting
  • Prognosis
  • INJURIES TO THE BLADDER
  • Figure 18-11. Mechanism of vesical injury. A direct blow over the full bladder causes increased intravesical pressure. If the bladder ruptures, it will usually rupture into the peritoneal cavity.
  • Pathogenesis and Pathology (Figure 18-11)
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • Figure 18-12. Extraperitoneal bladder rupture. Extravasation (at arrow) seen outside the bladder in the pelvis on cystogram.
  • Complications
  • Figure 18-13. Intraperitoneal bladder rupture. Cystogram shows contrast surrounding loops of bowel.
  • Treatment
  • A. Emergency Measures
  • B. Surgical Measures
  • Prognosis
  • INJURIES TO THE URETHRA
  • INJURIES TO THE POSTERIOR URETHRA
  • Etiology (Figure 18-14)
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • Figure 18-14. Injury to the posterior (membranous) urethra. The prostate has been avulsed from the membranous urethra secondary to fracture of the pelvis. Extravasation occurs above the triangular ligament and is periprostatic and perivesical.
  • C. X-Ray Findings
  • Figure 18-15. Ruptured prostatomembranous urethra shows free extravasation on urethrogram. No contrast medium is seen entering the prostatic urethra.
  • D. Instrumental Examination
  • Differential Diagnosis
  • Complications
  • Treatment
  • A. Emergency Measures
  • B. Surgical Measures
  • C. General Measures
  • Figure 18-16. Delayed repair of urethral injury. Normal voiding urethrogram after transpubic repair of stricture following prostatomembranous urethral disruption. Arrow indicates area of repair.
  • D. Treatment of Complications
  • Prognosis
  • INJURIES TO THE ANTERIOR URETHRA
  • Etiology (Figure 18-17)
  • Pathogenesis and Pathology
  • A. Contusion
  • Figure 18-17. Injury to the bulbous urethra. Left: Mechanism: usually a perineal blow or fall astride an object; crushing of urethra against inferior edge of pubic symphysis. Right: Extravasation of blood and urine enclosed within Colles' fascia (see Figures 18-1 through 18-9).
  • B. Laceration
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • Complications
  • Figure 18-18. Ruptured bulbar (anterior) urethra following straddle injury. Extravasation (at arrow) on urethrogram.
  • Treatment
  • A. General Measures
  • B. Specific Measures
  • C. Treatment of Complications
  • Prognosis
  • INJURIES TO THE PENIS
  • INJURIES TO THE SCROTUM
  • INJURIES TO THE TESTIS
  • BIBLIOGRAPHY
  • Emergency Diagnosis and Management
  • Injuries to the Kidney
  • Injuries to the Ureter
  • Injuries to the Bladder
  • Injuries to the Urethra
  • Injuries to the Penis
  • Injuries to the Scrotum
  • 19 Immunology & Immunotherapy of Urologic Cancers
  • TUMOR ANTIGENS
  • Humoral Immunity
  • Antibodies in Cancer Diagnosis and Detection
  • A. Prostate Cancer
  • B. Renal Cell Carcinoma
  • C. Bladder Cancer
  • D. Germ Cell Tumors
  • E. Radioimmunodetection
  • Immunotherapy with Monoclonal Antibodies
  • Cell-Mediated Immunity
  • Immunotherapy Involving Cell-Mediated Immunity
  • Active Immunotherapy: Vaccination
  • Nonspecific Active Immunotherapy: Cytokines and Biologic Response Modifiers
  • Immunomodulation
  • Adoptive Immunotherapy
  • BIBLIOGRAPHY
  • 20 Chemotherapy of Urologic Tumors
  • PRINCIPLES OF SYSTEMIC THERAPY
  • A. Clinical Uses of Chemotherapy
  • B. Chemotherapeutic Agents and Their Toxicity
  • C. Unique Features of Genitourinary Malignancies
  • Table 20-1. Commonly used chemotherapeutic agents in urologic oncology, and their toxicity.
  • GERM CELL MALIGNANCIES
  • A. Overview
  • B. Use of Chemotherapy for Patients with Stage I and II Disease
  • Table 20-2. Commonly used chemotherapeutic regimens in urologic oncology.
  • C. Use of Chemotherapy in Patients with Advanced Disease
  • D. Adjunctive Surgery and "Salvage" Therapy
  • TRANSITIONAL CELL CARCINOMA OF THE UROEPITHELIUM
  • A. Nonmetastatic Disease
  • B. Metastatic Disease
  • RENAL CELL CARCINOMA
  • HORMONE-REFRACTORY PROSTATE CANCER
  • BIBLIOGRAPHY
  • 21 Urothelial Carcinoma: Cancers of the Bladder, Ureter, & Renal Pelvis
  • BLADDER CARCINOMAS
  • Incidence
  • Risk Factors and Pathogenesis
  • Staging
  • Histopathology
  • Figure 21-1. Staging of bladder cancer.
  • A. Normal Urothelium
  • B. Papilloma/PUNLMP
  • C. Transitional Cell Carcinoma
  • D. Nontransitional Cell Carcinomas
  • Figure 21-2. A: Normal urothelium (125x). B: Moder-ately well differentiated, papillary bladder cancer (60x). C: Carcinoma in situ (200x).
  • E. Rare Epithelial and Nonepithelial Cancers
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • Table 21-1. Exfoliated markers for the detection of bladder cancer.
  • D. Imaging
  • E. Cystourethroscopy and Tumor Resection
  • Figure 21-3. Image of the urinary bladder obtained on an intravenous urogram. The filling defect represents a papillary bladder cancer.
  • Natural History and Selection of Treatment
  • A. Standard Histopathological Assessment
  • Figure 21-4. MRI scan of invasive bladder carcinoma: A: T1-weighted image; B: T2-weighted image. Bladder wall invasion is best assessed on T2-weighted images because of heightened contrast between tumor (asterisks) and detrusor muscle along with ability to detect interruption of the thin high-intensity line representing normal bladder wall. The heterogeneous appearance of the prostate (arrow) on the T2-weighted image owes to benign prostatic hypertrophy, confirmed at cystectomy. MRI, magnetic resonance imaging.
  • Table 21-2. Initial treatment options for bladder cancers.
  • B. Molecular Markers
  • C. Treatment Selection
  • Treatment
  • A. Intravesical Chemotherapy
  • Table 23-3. Delivery of intravesical chemotherapy or immunotherapy.
  • B. Surgery
  • C. Radiotherapy
  • D. Chemotherapy
  • E. Combination Therapy
  • URETERAL AND RENAL PELVIC CANCERS
  • Incidence
  • Etiology
  • Pathology
  • Staging and Natural History
  • Table 21-4. Staging of ureteral and renal pelvic carcinoma.
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • C. Imaging
  • Figure 21-5. Filling defect representing a transitional cell carcinoma (arrow) on retrograde pyelography.
  • D. Ureteropyeloscopy
  • Figure 21-6. Computed tomography scan showing the presence of a renal pelvic tumor (arrow).
  • Treatment
  • BIBLIOGRAPHY
  • Bladder Carcinomas
  • Ureteral and Renal Pelvic Cancers
  • 22 Renal Parenchymal Neoplasms
  • BENIGN TUMORS
  • Renal Oncocytoma
  • Angiomyolipoma (Renal Hamartoma)
  • Figure 22-1. Histologic section of a grade I (benign renal oncocytoma (original magnification, ×100).
  • Figure 22-2. Computed tomogram of an angiomyolipoma (arrows).
  • Other Rare Benign Renal Tumors
  • ADENOCARCINOMA OF THE KIDNEY (RCC)
  • Etiology
  • Pathology
  • Figure 22-3. Photomicrograph of clear cell renal adenocarcinoma (original magnification, ×125).
  • Pathogenesis
  • Tumor Staging and Grading
  • A. Tumor Staging
  • Table 22-1. TNM classification system for renal cell carcinoma.a
  • B. Tumor Grading
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Paraneoplastic Syndromes
  • C. Laboratory Findings
  • D. X-Ray Findings
  • E. Ultrasonography
  • F. CT Scanning
  • G. Renal Angiography
  • H. Radionuclide Imaging
  • Figure 22-4. A: Ultrasound image of a simple renal cyst showing renal parenchyma (long arrows), cyst wall (arrowheads), and a strong posterior wall (short arrows). B: Ultrasound image of a solid renal mass (arrows).
  • Figure 22-5. Computed tomogram (contrast enhancement) of a renal cell carcinoma (arrows).
  • I. Magnetic Resonance Imaging
  • J. Positron Emission Tomography (PET) and Targeted Imaging
  • Figure 22-6. Right renal angiogram showing typicalneovascularity (arrows) in a large lower pole renal cell cancer.
  • Figure 22-7. Transaxial magnetic resonance image (T2) of a renal cell carcinoma (long arrows) with vena caval tumor thrombus (short arrows).
  • K. Fine-Needle Aspiration
  • L. Instrumental and Cytologic Examination
  • Differential Diagnosis
  • Treatment
  • A. Specific Measures
  • Figure 22-8. Boundaries of a left radical nephrectomy. Dotted line represents both the surgical margin and Gerota's fascia.
  • Figure 22-9. Coronal magnetic image (T1) of a large vena caval tumor thrombus (long arrows) in a patient with renal cell carcinoma. Thrombus extends just to entrance of hepatic veins (short arrows).
  • B. Follow-up Care
  • Prognosis
  • NEPHROBLASTOMA (WILMS TUMOR)
  • Etiology
  • Pathogenesis and Pathology
  • Figure 22-10. Wilms tumor with characteristic tubular/glomeruloid structures and blastema (original magnification ×40).
  • Tumor Staging
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Analysis
  • C. X-Ray Imaging
  • D. Needle Biopsy
  • Differential Diagnosis
  • Treatment
  • A. Surgical Measures
  • B. Chemotherapy
  • C. Radiation Therapy
  • Prognosis
  • SECONDARY RENAL TUMORS
  • BIBLIOGRAPHY
  • 23 Neoplasms of the Prostate Gland
  • BENIGN PROSTATIC HYPERPLASIA
  • Incidence and Epidemiology
  • Etiology
  • Pathology
  • Figure 23-1. A: Schematic lateral view of the prostate. B: Cut section of the same. C: Transverse view of area shown in B.
  • Pathophysiology
  • Figure 23-2. Whole mount of prostate at level of midprostatic urethra. Note verumontanum (V) and areas of prostate cancer (CAP) in peripheral zone and areas of benign prostatic hyperplasia (BPH) in transition zone.
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Imaging
  • Table 23-1. Questionnaire for international prostate symptom score.
  • E. Cystoscopy
  • F. Additional Tests
  • Differential Diagnosis
  • Treatment
  • A. Watchful Waiting
  • B. Medical Therapy
  • Table 23-2. Classification of medical therapy and recommended dosage in BPH.
  • C. Surgical Therapy
  • CARCINOMA OF THE PROSTATE
  • Incidence and Epidemiology
  • Pathology
  • Figure 23-3. Gleason primary grade 3 (A), grade 4 (B), and grade 5 (C) cancer (200×). A: Glands are well developed with variation in contour and morphology. The glands grow in an infiltrative pattern. Nuclear features of malignancy include mild nuclear enlargement, granular chromatin, and nucleoli. B: Malignant cells have trabecular, glandular, and infiltrative growth pattern forming small solid nests and abortive, fused glandular lumens. Malignant nuclear features include marked nuclear enlargement and macronucleoli. C: Highly infiltrative growth pattern with single cells and small nests of malignant epithelial cells. Cytologic features include marked nuclear pleomorphism and anisonucleosis with irregular contours, coarse irregular chromatin distribution, and macronucleoli.
  • Figure 23-4. Whole body bone scintigram showing multiple bone metastases.
  • Molecular Genetics and Pathobiology
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. General Laboratory Findings
  • D. Prostate-Specific Antigen and Other Tumor Markers
  • Diagnosis and Evaluation
  • A. Prostate Biopsy
  • B. Grading and Staging
  • C. Imaging
  • Table 23-3. TNM staging system for prostate cancer.
  • D. Multivariable Risk Assessment
  • Figure 23-5.
  • Figure 23-6.
  • Prostate Cancer Screening and Chemoprevention
  • Chemoprevention
  • Treatment
  • A. Localized Disease
  • B. Recurrent Disease
  • C. Metastatic Disease
  • Table 23-4. Androgen ablation therapy for prostate cancer.
  • BIBLIOGRAPHY
  • Prostate Gland Anatomy
  • Benign Prostatic Hyperplasia
  • Prostate Cancer
  • Epidemiology and Guidelines
  • Genetics, Pathobiology, and Pathology
  • Screening and Chemoprevention, and Biopsy
  • Serum Tumor Markers
  • Staging and Risk Assessment
  • Imaging
  • Prostate Biopsy
  • Radical Prostatectomy
  • Radiation
  • Active Surveillance
  • Cryotherapy and HIFU
  • Quality of Life
  • Relapse and Androgen Deprivation
  • Secondary Therapy and Chemotherapy
  • 24 Genital Tumors
  • TUMORS OF THE TESTIS
  • GERM CELL TUMORS OF THE TESTIS
  • Epidemiology and Risk Factors
  • Classification
  • Tumorigenic Hypothesis for Germ Cell Tumor Development
  • Figure 24-1. Tumorigenic model for germ cell tumors of the testis.
  • Pathology
  • A. Seminoma (35%)
  • B. Embryonal Cell Carcinoma (20%)
  • C. Teratoma (5%)
  • D. Choriocarcinoma (1%)
  • E. Mixed Cell Type (40%)
  • F. Carcinoma In Situ
  • Patterns of Metastatic Spread
  • Clinical Staging
  • Clinical Findings
  • A. Symptoms
  • Table 24-1. TNM classification of tumors of the testis.
  • B. Signs
  • C. Laboratory Findings and Tumor Markers
  • Table 24-2. Incidence of elevated tumor markers by histologic type in testis cancer.
  • D. Imaging
  • Differential Diagnosis
  • Treatment
  • A. Low-Stage Seminoma
  • B. High-Stage Seminoma
  • C. Low-Stage Nonseminomatous Germ Cell Tumors
  • D. High-Stage Nonseminomatous Germ Cell Tumors
  • Figure 24-2. Upper: Computed tomography scan of patient with bulky retroperitoneal mass after radical orchiectomy for embryonal carcinoma. Lower: Residual cystic mass after chemotherapy; it was resected and found to be teratoma.
  • Follow-up Care
  • Prognosis
  • Table 24-3. Risk classification for testicular cancer.
  • NON-GERM CELL TUMORS OF THE TESTIS
  • LEYDIG CELL TUMORS
  • Epidemiology and Pathology
  • Clinical Findings
  • Treatment and Prognosis
  • SERTOLI CELL TUMORS
  • Epidemiology and Pathology
  • Clinical Findings
  • Treatment
  • GONADOBLASTOMAS
  • Epidemiology and Pathology
  • Clinical Findings
  • Treatment and Prognosis
  • SECONDARY TUMORS OF THE TESTIS
  • LYMPHOMA
  • Epidemiology and Pathology
  • Clinical Findings
  • Treatment and Prognosis
  • LEUKEMIC INFILTRATION OF THE TESTIS
  • METASTATIC TUMORS
  • EXTRAGONADAL GERM CELL TUMORS
  • Epidemiology and Pathology
  • Clinical Findings
  • Treatment and Prognosis
  • TUMORS OF THE EPIDIDYMIS, PARATESTICULAR TISSUES, AND SPERMATIC CORD
  • TUMORS OF THE PENIS
  • Epidemiology and Risk Factors
  • Pathology
  • A. Precancerous Dermatologic Lesions
  • B. Carcinoma In Situ (Bowen Disease, Erythroplasia of Queyrat)
  • C. Invasive Carcinoma of the Penis
  • Patterns of Spread
  • Tumor Staging
  • Table 24-4. TNM classification of tumors of the penis.
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Imaging
  • Differential Diagnosis
  • Treatment
  • A. Primary Lesion
  • B. Regional Lymph Nodes
  • Figure 24-3. Comparison of limits of dissection of complete (dashed line) versus limited (solid line) inguinal lymphadenectomy.
  • C. Systemic Disease
  • Prognosis
  • Other Penile Tumors
  • TUMORS OF THE SCROTUM
  • Figure 24-4. Management of penile carcinoma.
  • BIBLIOGRAPHY
  • Tumors of the Testis
  • Tumors of the Penis
  • 25 Urinary Diversion & Bladder Substitutions
  • PREOPERATIVE COUNSELING AND PREPARATION
  • INTESTINAL CONDUIT URINARY DIVERSION
  • Ileal Conduit
  • Jejunal Conduit
  • Colon Conduit
  • Figure 25-1. Ileal conduit.
  • Figure 25-2. Transverse colon conduit.
  • Figure 25-3. Creation of a submucosal tunnel in the wall of the colon to prevent ureteral reflux of urine. A: Incision in the tenia coli. B: Anastomosis of distal ureter to large intestine mucosa. C: Muscularis (tenia) approximated over ureter.
  • CONTINENT URINARY DIVERSION AND BLADDER SUBSTITUTION
  • General Considerations
  • Ureterosigmoidostomy
  • Figure 25-4. Ureterosigmoidostomy.
  • Reservoirs Constructed of Small Intestine
  • Figure 25-5. Construction of a T pouch. A: Two segments of small intestine are isolated; one portion will form the reservoir, and the smaller, more proximal portion will form the antireflux segment. B: The longer reservoir portion of the segments is folded into a V. The smaller, antireflux segment is fixed to the serosa of the reservoir portion. C: The antireflux segment has been opened and tapered with a stapling device. The ileal segments selected for the reservoir portion of the pouch are joined anteriorly and then opened, exposing the mucosa. As the opening reaches the ostium of the antireflux segment, the incisions are carried laterally and create wide flaps that can then be closed over the ostium to cover the tapered antireflux segment. D: The reservoir portion is closed.
  • Figure 25-6. Bladder substitutes constructed entirely of small intestine. A: Forty to forty-five centimeters of small intestine is selected. B: Small intestine is opened and fashioned into a W. The ureters are reimplanted into the second and third limbs of the reservoir, and the reservoir is attached to the urethra. C: Small intestine is folded into a J with the most proximal portion of the segment not opened. The ureters are reimplanted into the intact ileal segment of the reservoir, and the reservoir is attached to the urethra.
  • Reservoirs Constructed of Large Intestine
  • Figure 25-7. Use of the ileocecal segment to construct (A) a bladder substitute attached to the urethra or (B) a continent urinary reservoir placed in the abdomen using plicated terminal ileum as a stoma.
  • Postoperative Care
  • COMPLICATIONS
  • Figure 25-8. A: Continent urinary reservoir constructed from the ileocecal segment. B: Bowel detubularized. C: Stoma constructed by tapering the terminal ileum with intestinal stapling instrument or sutures. D: Completed stoma.
  • Metabolic and Nutritional Disorders
  • Stoma
  • Table 25-1. Common peristomal skin problems and their management.
  • Continence and Urinary Function
  • Pyelonephritis and Renal Deterioration
  • Calculi
  • BIBLIOGRAPHY
  • General
  • Colon Conduit
  • Continent Urinary Diversion and Bladder Substitution
  • Ureterosigmoidostomy
  • Complications
  • Ostomy Care
  • 26 Radiotherapy of Urologic Tumors
  • GENERAL PRINCIPLES OF RADIOTHERAPY
  • Mechanisms of Cytotoxicity
  • Radiation Sensitivity and Tolerance
  • Dose Per Fraction Considerations
  • Altered Fractionation Schedules
  • Brachytherapy
  • Figure 26-1. Brachytherapy: Example of an ultrasound-guided permanent interstitial implant of the prostate.
  • SPECIFIC UROLOGIC SITES
  • Prostate Cancer
  • Figure 26-2. Example of intraluminal brachytherapy for urethral cancer. (Reproduced with permission from Sailer SL, Shipley WU, Wang CC: Carcinoma of the female urethra: A review of results with radiation therapy. J Urol 1988;140:1.)
  • Figure 26-3. As is shown, men treated by radical prostatectomy had a better adjusted survival rate than men without prostate cancer suggesting selection biases for favorable outcomes for these men compared with those treated with radiotherapy. (From Giordano SH et al: Limits of observational data in determining outcomes from cancer therapy. Cancer 2008;112:2456–2466.)
  • A. Conventional Treatment
  • Dose Escalation Radiotherapy
  • A. Brachytherapy
  • B. Neutrons, Protons, and Heavy-Charged Particles
  • Table 26-1. Major Phase III randomized trials addressing the issue of dose of radiation.
  • Hormonal Therapy and Radiotherapy
  • A. Postoperative Radiotherapy and Salvage Brachytherapy
  • Table 26-2. External beam radiotherapy +/− short-term neoadjuvant ADT.
  • Table 26-3. External beam radiotherapy +/− long-term adjuvant +/− neoadjuvant ADT.
  • B. Complications of Radiotherapy for Prostate Cancer
  • NONPROSTATE GENITOURINARY CANCERS
  • Urinary Tract Tumors
  • Bladder Cancer
  • A. EBRT Management of Bladder Cancer
  • B. Combined Modality Management of Muscle-Invasive Bladder Cancer (Transurethral Bladder Resection, Chemotherapy, and EBRT) and Organ Preservation
  • Table 26-4. Contemporary combined modality bladder preservation trials.
  • C. Improving Treatment Outcomes
  • D. Toxicity of Radiotherapy Treatment for Bladder Cancer
  • Cancers of the Kidney, Renal Pelvis, and Ureter
  • URETHRAL CANCERS
  • Cancer of the Female Urethra
  • Cancer of the Penis and Male Urethra
  • Testicle Tumors
  • Germ Cell Tumors
  • Table 26-5. Surveillance guidelines for stage I testicular seminoma.
  • Figure 26-4. A: Incidence and location of lymph nodes at risk for an early-stage left-sided testicular seminoma. B: Incidence and location of lymph nodes at risk for an early-stage right-sided testicular seminoma. (Adapted from Donohue JP et al: Distribution of nodal nets in nonseminomatous testis cancer. J Urol 1982;126:315.)
  • Figure 26-5. A: Para-aortic treatment field ("limited-field") for prophylactic nodal irradiation for stage I testicular seminoma. B: Pelvic and para-aortic treatment field ("hockey stick or dog-leg") for prophylactic nodal irradiation for stage I testicular seminoma.
  • Figure 26-6. Risk-adapted strategy for the management of stage I seminoma.
  • A. Toxicity from Radiotherapy Treatment of Testicular Seminoma
  • SUMMARY
  • BIBLIOGRAPHY
  • General Principles of Radiobiology, and Prostate Cancer
  • Urinary Track Tumors
  • Bladder Cancer
  • Cancers of the Kidney, Renal Pelvis, and Ureter
  • Cancer of the Female Urethra
  • Cancer of the Penis and Male Urethra
  • Testicle Tumors
  • 27 Neurophysiology & Pharmacology of the Lower Urinary Tract
  • INTRODUCTION
  • NEURAL CIRCUITS CONTROLLING STORAGE AND EXPULSION OF URINE
  • PARASYMPATHETIC PATHWAYS
  • SYMPATHETIC PATHWAYS
  • SOMATIC PATHWAYS
  • AFFERENT PATHWAYS
  • AFFERENT SIGNALING FROM THE UROTHELIUM/SUBUROTHELIUM
  • NEURAL CONTROL OF BLADDER FILLING
  • NEURAL CONTROL OF BLADDER EMPTYING
  • Vesico-Bulbo-Vesical Micturition Reflex
  • Vesico-Spinal-Vesical Micturition Reflex
  • TARGETS FOR PHARMACOLOGIC INTERVENTION
  • CENTRAL NERVOUS SYSTEM TARGETS
  • Opioid Receptors
  • Serotonin (5-HT) Mechanisms
  • GABA Mechanisms
  • Noradrenaline Mechanisms
  • Dopamine Mechanisms
  • NK-1 Receptor Mechanisms
  • PERIPHERAL TARGETS
  • Muscarinic Receptors
  • Antimuscarinics
  • Adrenergic Receptors
  • A. Alpha-ARs
  • B. Beta-ARs
  • Ion Channels
  • A. Calcium Channels
  • B. Potassium Channels
  • Vanilloid Receptors
  • Botulinum Toxin-Sensitive Mechanisms
  • SUMMARY AND FUTURE ASPECTS
  • BIBLIOGRAPHY
  • 28 Neuropathic Bladder Disorders
  • NORMAL VESICAL FUNCTION
  • ANATOMY AND PHYSIOLOGY
  • The Bladder Unit
  • The Sphincteric Unit
  • The Ureterovesical Junction
  • INNERVATION AND NEUROPHYSIOLOGY
  • Nerve Supply
  • The Micturition Reflex
  • The Storage Function
  • Cerebral (Suprapontine) Control
  • Neurotransmitters and Receptors
  • Figure 28-1. Afferent and efferent pathways and central nervous system centers involved in micturition.
  • Figure 28-2. Pathways and central nervous system centers involved in urine storage.
  • URODYNAMIC STUDIES (SEE ALSO CHAPTER 27)
  • Micturition
  • Figure 28-3. Simultaneous recording of bladder and urethral pressure as well as electromyographic recording of the external sphincter. Note the dyssynergic response. With bladder contraction, there is increased activity in the external sphincter and pelvic floor, as recorded by the intraurethral pressure and electromyogram tracings.
  • Uroflowmetry
  • Cystometry
  • Urethral Pressure Recordings
  • Electromyography
  • ABNORMAL VESICAL function
  • CLASSIFICATION OF NEUROPATHIC BLADDER
  • Injury to the Detrusor Motor Nucleus
  • Injury to the Afferent Feedback Pathways
  • Injury Causing Poor Detrusor Distensibility
  • Selective Injury to the External Sphincter
  • SPINAL SHOCK AND RECOVERY OF VESICAL FUNCTION AFTER SPINAL CORD INJURY
  • Diagnosis of Neurogenic Bladder
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • E. Instrumental Examination
  • F. Urodynamic Studies
  • Figure 28-4. Spinal cord injury at T12. Simultaneous recording of intravesical and urethral pressure with bladder filling. Note the rise in intravesical pressure associated with unstable activity of the external sphincter, as reflected on the urethral pressure tracing.
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. X-Ray Findings
  • D. Instrumental Examination
  • E. Urodynamic Studies
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • E. Instrumental Examination
  • F. Urodynamic Studies
  • G. Denervation Hypersensitivity
  • DIFFERENTIAL DIAGNOSIS OF NEUROGENIC BLADDER
  • Cystitis
  • Chronic Urethritis
  • Vesical Irritation Secondary to Psychic Disturbance
  • Interstitial Cystitis
  • Cystocele
  • Bladder Outlet Obstruction
  • TREATMENT OF NEUROPATHIC BLADDER
  • Neurogenic Overactive Bladder
  • A. Patient with Reasonable Bladder Capacity
  • B. Patient with Markedly Diminished Functional Vesical Capacity
  • C. Muscarinic Receptor Antagonist
  • D. Intravesical Instillation of Medications
  • E. Botulinum-A Toxin
  • F. Neurostimulation (Bladder Pacemaker)
  • Neurogenic Areflexic Bladder
  • A. Bladder Training and Care
  • B. Intermittent Catheterization
  • C. Surgery
  • D. Parasympathomimetic Drugs
  • Neurogenic Bladder Associated with Spina Bifida
  • A. Conservative Treatment
  • B. Surgical Treatment
  • Neurostimulation
  • COMPLICATIONS OF NEUROGENIC BLADDER
  • Infection
  • A. Treatment of Pyelonephritis
  • B. Treatment of Epididymitis
  • Hydronephrosis
  • Calculus
  • A. Bladder Stones
  • B. Ureteral Stones
  • C. Renal Stones
  • Renal Amyloidosis
  • Sexual Dysfunction
  • Autonomic Dysreflexia
  • PROGNOSIS
  • BIBLIOGRAPHY
  • 29 Urodynamic Studies
  • FUNCTIONS RELEVANT TO URODYNAMICS AND TESTS APPLICABLE TO EACH
  • PHYSIOLOGIC AND HYDRODYNAMIC CONSIDERATIONS
  • URINARY FLOW RATE
  • Outlet Resistance
  • Mechanical Outlet Resistance
  • Variations in Normal Flow Rate
  • Nomenclature
  • Figure 29-1. Uroflowmetry. Basic elements of maximum flow, average flow, total flow time, and total volume voided.
  • Pattern Measurement of Flow Rate
  • Figure 29-2. Classic normal flow rate, with peak of about 30 mL/s and average of about 20 mL/s. On the horizontal scale, one large square equals 5 seconds.
  • Figure 29-3. Flow rate of "supervoider." Maximum flow rate exceeds limits of chart. Tracing shows fast buildup and complete bladder emptying of large volume of urine in a very short period. On the horizontal scale, one large square equals 5 seconds.
  • Figure 29-4. Normal flow rate with some variation in appearance of curve. Note the rapid pressure rise but progressive increase to maximum, followed by a sharp drop. There is also fluctuation in ascending limb of tracing. On the horizontal scale, one large square equals 5 seconds.
  • Figure 29-5. Rather low flow rate (not exceeding 10 mL/s), yet at one point, the peak reaches 27–32 mL/s. Note again fluctuation in flow. On the horizontal scale, one large square equals 5 seconds.
  • Figure 29-6. Very low flow rate of short duration and small volume. Note that maximum flow is not >15 mL/s; however, flow average is <10 mL/s, and flow is almost completely interrupted in the middle. On the horizontal scale, one large square equals 5 seconds.
  • Figure 29-7. Classic flow rate due to abdominal straining with no detrusor activity. See effect of spurts of urine with complete interruption between them; patient cannot sustain increased intra-abdominal pressure. On the horizontal scale, one large square equals 5 seconds.
  • Figure 29-8. Flow rate in a case of urinary obstruction showing very low average flow rate (not above 5 or 6 mL/s). Prolonged duration of flow is associated with incomplete emptying. On the horizontal scale, one large square equals 5 seconds.
  • BLADDER FUNCTION
  • Bladder Capacity, Compliance, and Sensation
  • Bladder Compliance (Accommodation)
  • Figure 29-9. Classic low flow rate of bladder outlet obstruction (benign prostatic hypertrophy), markedly prolonged flow time, and fluctuation due to attempt at improving flow by increasing intra-abdominal pressure. On the horizontal scale, one large square equals 5 seconds.
  • Figure 29-10. Cystometrogram of patient with normal bladder capacity. Note the stable intravesical pressure during filling phase; slight rise at end of filling phase, indicating bladder capacity perceived as sense of fullness; and sharp rise at end (voiding contraction).
  • Contractility and Voluntary Control
  • Responses to Drugs
  • Recording of Intravesical Pressure
  • Figure 29-11. Simultaneous recording of voiding con-traction and resulting flow rate. Note the normal range of intravesical pressure during voiding phase as well as ade-quate normal flow rate (shown in Figure 29-4). On the horizontal scale, one large square equals 5 seconds.
  • A. Pathologic Changes in Bladder Capacity
  • Figure 29-12. Recording of bladder pressure simultaneously with flow rate. Note the slightly higher intravesical pressure with high flow rate, which, at its maximum, is that of a supervoider (see Figure 29-3). On the horizontal scale, one large square equals 5 seconds.
  • B. Pathologic Changes in Accommodation (Compliance)
  • Figure 29-13. Simultaneous recording of flow rate and intra-abdominal pressure; intravesical pressure overlap in top recording. Note the very high voiding pressure. How-ever, flow rate is relatively low, with some interruption most likely due to sphincteric overactivity. On the hori-zontal scale, one large square equals 5 seconds.
  • Figure 29-14. Simultaneous recording of intra-abdominal and intravesical pressures. If one considers only intravesical pressure (upper recording), one might assume adequate detrusor contraction. Comparison with intra-abdominal pres-sure (lower recording) shows that they are almost identical and that there is no detrusor contraction at all.
  • Figure 29-15. Simultaneous recording of two measurements—intravesical pressure (top) and intra-abdominal pressure (bottom)—on a single channel. The difference between the two can be clearly seen as pure detrusor contraction.
  • C. Pathologic Changes in Sensation
  • D. Pathologic Changes in Contractility
  • Table 29-1. Causes of reduced or increased bladder capacity.
  • Table 29-2. Relationship between intravesical pressure and capacity in various diseases.
  • Table 29-3. Variations in detrusor contractility in various diseases.
  • SPHINCTERIC FUNCTION
  • Profilometry
  • A. Membrane Catheter Technique
  • B. Microtransducer Technique
  • Figure 29-16. Membrane catheter showing radiopaque markers. Note the two membrane chambers for urethral pressure measurements and four separate channels—two channels for urethral pressure recording, one for bladder pressure recording, and one for bladder filling—each of which is connected to a separate ending. (Reproduced, with permission, from Tanagho EA, Jonas U: Membrane catheter: Effective for recording pressure in lower urinary tract. Urology 1977;10:173.)
  • Figure 29-17. Simultaneous recording of bladder pressure, flow rate, and electromyography of anal sphincter. With rise in bladder pressure for voiding, start of flow rate has a smooth, continuous, bell-shaped curve. Note also the complete absence of electromyographic activity of the anal sphincter throughout the voiding act. On the horizontal scale, one large square equals 5 seconds.
  • Electromyographic Study of Sphincteric Function
  • Pressure Measurement for Evaluation of Sphincteric Function
  • Figure 29-18. Urethral pressure profile and its components. Note the functional length, anatomic length, and the shape of the profile, with maximum closure pressure in the middle segment of the urethra rather than at the level of the internal meatus. (Reproduced, with permission, from Bradley W: Cystometry and sphincter electromyography. Mayo Clin Proc 1976;329:335.)
  • A. Total Pressure
  • B. Closure Pressure
  • C. Distribution of Closure Pressure
  • D. Functional Length of Sphincteric Unit
  • Figure 29-19. Normal male urethral pressure profile showing progressive rise throughout prostatic segment and peak being reached in membranous urethra. (Reproduced, with permission, from Tanagho EA: Membrane and micro-transducer catheters: Their effectiveness for profilometry of the lower urinary tract. Urol Clin North Am 1979;6:110.)
  • Dynamic Changes in Pressure Profile
  • Figure 29-20. Simultaneous recording of intraurethral (U) and intravesical (B) pressures and their responses to coughing and bearing down. Rise in intravesical pressure as a result of increase in intra-abdominal pressure is associated with simultaneous rise in intraurethral pres-sure, maintaining a constant closure pressure.
  • Characteristics of Normal Pressure Profile (Figure 29-23)
  • Figure 29-21. Urethral pressure profile of normal woman in sitting and standing positions. Note the marked improvement in closure pressure (in both functional length and magnitude) when patient stands up. (Reproduced, with permission, from Tanagho EA: Urodynamics of female urinary incontinence with emphasis on stress incontinence. J Urol 1979;122:200.)
  • Figure 29-22. Right: Urethral pressure profile in normal range. U, urethra; B, bladder. Left: Main point of effect of hold maneuver is significant increase in closure pressure of urethra (U) without change in bladder pressure (B)—act of voluntary sphincter.
  • Pressure Profile in Pathologic Conditions
  • A. Urinary Stress Incontinence
  • Figure 29-23. Recording of normal female urethral pressure profile, showing basic features and actual values, including anatomic as well as functional length. U, urethra; B, bladder. (Reproduced, with permission, from Tanagho EA: Membrane and microtransducer catheters: Their effectiveness for profilometry of the lower urinary tract. Urol Clin North Am 1979;6:110.)
  • B. Urinary Urge Incontinence
  • C. Combination of Stress and Urge Incontinence
  • D. Postprostatectomy Incontinence
  • Figure 29-24. Three mechanisms of urinary urge incontinence. Left: Normal sphincter activity exceeded by hyperactive detrusor. Center: Normal detrusor, without any overactivity, yet unstable urethra with marked drop in urethral pressure leading to leakage. Right: Most common combination—some rise in intravesical pressure due to detrusor hyperirritability associated with drop in urethral pressure due to sphincteric relaxation. U, urethra; B, bladder.
  • E. Detrusor/Sphincter Dyssynergia
  • Value of Simultaneous Recordings
  • VIDEOURODYNAMIC
  • Videourodynamic Equipment
  • Indications for Videourodynamic
  • Figure 29-25. Videourodynamic showing bilateral ureteral reflux and urinary incontinence in a small contracted bladder. The bladder compliance is poor; however, it is masked by both the reflux and urinary leakage.
  • Figure 29-26. Videourodynamic after pubovaginal sling in a patient with urinary retention showing high voiding pressure and dilation of proximal urethra above the sling during voiding.
  • LEAK POINT PRESSURE
  • Detrusor Leak Point Pressure
  • Abdominal/Valsalva Leak Point Pressure
  • How to Measure the Abdominal Leak Point Pressure
  • BIBLIOGRAPHY
  • Urethra and Bladder
  • Urinary Flow Rate
  • Electromyography
  • Urodynamic Testing
  • Videourodynamic
  • 30 Urinary Incontinence
  • PATHOPHYSIOLOGY
  • GENERAL APPROACH
  • STRESS URINARY INCONTINENCE
  • Anatomy
  • Figure 30-1. Lateral cystograms in a 53-year-old woman with stress incontinence. A: Preoperative, relaxed. Note slightly low-lying vesicourethral junction. The posterior vesicourethral angle is near normal. B: With straining, excessive downward and posterior mobility of the vesicourethral segment is shown. Posterior angle almost disappears.
  • Figure 30-2. Diagrammatic representation of (A) the angles considered when assessing adequacy of bladder support (posterior vesicourethral angle; angle of inclination) and (B) the "SCIPP line" (sacrococcygeal inferior pubic point) and its relationship to the bladder base and the vesicourethral segment as a reference to adequate pelvic support.
  • Figure 30-3. Lateral cystograms in two continent women in the relaxed state. A perpendicular line from the anterior vesicourethral angle over the long axis of the pubic bone crosses the bone near the junction of the middle and lower thirds.
  • Diagnosis
  • Figure 30-4. Lateral cystograms in two young continent women. A: Relaxed state, 28-year-old woman. B: With straining, the vesicourethral segment is displaced 0.5 cm downward and posteriorly. C: Relaxed state, 34-year-old woman. D: With straining, the vesicourethral segment is displaced 0.8 cm downward and 1 cm posteriorly.
  • Urodynamic Characteristics of Stress Incontinence
  • A. Urethral Pressure Profile
  • Figure 30-5. Normal urethral pressure. Closure pressure at the level of the internal meatus is very low; the pressure rises progressively to reach its maximum at approximately the middle third of the urethra—the site of maximal condensation of striated muscle.
  • B. Functional Urethral Length
  • C. Response to Stress
  • D. Voluntary Increase in Urethral Closure Pressure
  • E. Response to Bladder Distention and Change in Position
  • F. Abdominal Leak Point Pressure
  • Treatment
  • Figure 30-6. Urethral pressure profile for a patient in sitting and upright positions. An approximately 50% increase in urethral closure pressure occurs when the patient assumes the upright position. Urethral functional length is well sustained.
  • Figure 30-7. A: Intravesical and urethral pressure responses to the stresses of coughing, bearing down, and the hold maneuver. Note the sharp increase in intra-abdominal pressure reflected in intravesical pressure with coughing and the simultaneous greater increase in urethral pressure. The response is similar with bearing down. Closure pressure is maintained and even augmented during these periods of stress. The hold maneuver (recording membrane is in the proximal urethra) produces a minimal response in closure pressure of the proximal urethra. B: Recording comparable with that in A, but the membrane is in the midurethra. Note again the sustained closure pressure as a result of coughing and bearing down and the marked pressure increase in the midurethral segment with the hold maneuver.
  • Figure 30-8. A: Response to pelvic nerve stimulation. Note the simultaneous, equal pressure rise in the bladder, proximal urethra (U1), and midurethra (U2). B: Vesical and sphincteric responses to an injection of the parasympathetic drug methacholine chloride. Note again the simultaneous rise in pressure at the bladder, proximal urethra (U1), and midurethra (U2).
  • Figure 30-9. Response of the striated component to sacral nerve stimulation. Note that bladder pressure does not change and proximal urethral pressure (U1) rises only slightly, compared with the sharp and sustained increase in midurethral pressure (U2).
  • URGE INCONTINENCE
  • Figure 30-10. A: The resistance required to force the urethra open, overcoming both voluntary and involuntary sphincteric elements. With progressively increasing pressure, the urethra opens at the critical opening pressure (in this recording, about 85 mm Hg). Once the urethra is forced open, the resistance to flow drops precipitously and becomes sustained at the level of sustained urethral resistance (in this recording, roughly 50 mm Hg). B: A similar recording obtained after administration of curare, which completely blocks voluntary sphincteric responses. Note the appreciable drop in both critical opening pressure and sustained resistance. C: Recording after administration of both curare and atropine (a combination that eliminates the activity of smooth and voluntary sphincteric elements). The critical opening pressure drops markedly and is now equal to the sustained resistance; both are very low. D: An overlap of the three recordings shows the contribution of each muscular element: the voluntary component contributes roughly 50% of the total resistance, while the smooth component contributes the other 50%. The minimal residual resistance is a function of the collagen elastic element of the urethral wall; this collagen element has no sphincteric significance.
  • Figure 30-11. Urethral pressure profile. A: At rest. B: Stimulation of both the pudendal and the pelvic nerves incites the maximal response from both smooth and voluntary sphincteric elements. C: Pudendal stimulation alone demonstrates the contribution of the voluntary component. D: Pelvic nerve stimulation shows the response of the smooth-muscle component alone. Bottom tracings: Total maximal pressure profile obtained by stimulation of pelvic and pudendal nerves depicted by overlapping the profile of simultaneous stimulation of both nerves. The contribution and anatomic distribution of each element are clearly seen. Their summation results in the overall total responses recorded in B above.
  • Figure 30-12. Urethral pressure profile at rest and after subjecting an experimental animal to progressively increasing extrinsic pressure applied around the abdomen—not involving any muscular activity. A: Extrinsic pressure was increased by 25-mm Hg increments. Note the sharp increase in urethral closure pressure with each increment, marked after 25 and 50 mm Hg, less so after 75 and 100 mm Hg. The increase in urethral closure pressure is far higher than the increase in extrinsic pressure, which denotes not simple transmitted pressure but active muscular function. B: Curare administration demonstrates that much of the rise in closure pressure recorded in A results from the activity of the voluntary sphincter, which is lost after blockade by curare.
  • Figure 30-13. Urethral pressure profile with minimally filled bladder. Bladder pressure remains constant, but urethral pressure drops progressively. Closure pressure becomes minimal at the end of bladder filling.
  • Figure 30-14. Urethral pressure profile in moderately severe stress incontinence: closure pressure with patient in the sitting position with half-distended bladder, then after the upright position is assumed. Note that closure pressure is close to 75 cm H2O with the patient in the sitting position but decreases to approximately 35 cm H2O with the upright position. Note also the marked shortening of functional urethral length once the upright position is assumed.
  • Diagnosis
  • Figure 30-15. Urethral pressure profile in a female patient with moderate urinary stress incontinence. Note the relatively low closure pressure, the short functional urethral length, and the loss of closure pressure of the proximal 1.5 cm of urethra.
  • Figure 30-16. Urethral pressure profile in moderate stress incontinence. Note that, with the bladder relatively empty, closure pressure is close to the normal range. At the start of bladder filling, resting pressure is again normal; as filling progresses, bladder pressure remains stable and urethral closure pressure decreases progressively to a minimum with full bladder distention.
  • Figure 30-17. Effect of bladder filling and emptying on urethral pressure. Top: Effect of progressive filling, which leads to a gradual drop in urethral pressure. At the end of filling, urethral closure pressure is only a fraction of the relatively normal initial closure pressure. Bottom: At the start, the bladder is full. With gradual emptying, note the progressive buildup in urethral resistance and closure pressure.
  • Figure 30-18. A: Diagrammatic depiction of the retropubic space after mobilization of the anterior vaginal wall and placement of sutures, two on either side and far from the midline laterally. Distal sutures are opposite the midurethra, while proximal sutures are at the end of the vesicourethral junction. Sutures are attached to Cooper's ligament. B: Side view of suture placement with one side tied. The anterior vaginal wall acts as a broad sling, supporting and lifting the vesicourethral segment. The urethra is free in the retropubic space.
  • Figure 30-19. Top: Cross section shows the urethra free in the retropubic space with the anterior vaginal wall lifting and supporting it. Bottom: The urethra is compressed against the pubic bone when vaginal sutures are applied close to the urethra and fixed to the symphysis pubis. The vaginal suspension has various forms; in some, the tissue is gathered behind the bladder neck (eg, the Kelly procedure), while others rely on sutures in the paravaginal tissues that are passed bluntly to the suprapubic area by a needle to be tied over the rectus sheath. This technique was originally described by Pereyra in 1959 and subsequently was modified—in 1973 by Stamey, who added endoscopic confirmation of suture placement and the degree of compression, and in 1981 by Raz. Most of these techniques have a high initial success rate; however, there is some concern about the long-term results. Hence, the retropubic approach remains the recommended procedure.
  • Treatment
  • MIXED URINARY INCONTINENCE
  • Diagnosis
  • Treatment
  • OVERFLOW INCONTINENCE
  • Diagnosis
  • Treatment
  • NEUROPATHIC INCONTINENCE
  • A. Failure of Bladder Storage Function
  • B. Failure of Sphincter Function
  • Diagnosis
  • Figure 30-20. Urodynamic recording in a patient with evidence of detrusor/sphincter dyssynergia, showing spontaneous activity in the bladder associated with a burst of activity in the external sphincter interrupting voiding. This represents a classic demonstration of upper motor neuron dysfunction leading to urinary incontinence as a result of detrusor hyperactivity or hyperreflexia. R, rectal pressure; B, bladder pressure; U2, distal urethral pressure.
  • Treatment
  • A. Failure of Storage Function
  • B. Failure of Sphincter Mechanism
  • C. Surgical Management
  • BIBLIOGRAPHY
  • 31 Disorders of the Adrenal Glands
  • DISEASES OF THE ADRENAL CORTEX
  • CUSHING'S SYNDROME
  • Pathophysiology
  • Pathology
  • Figure 31-1. The hypothalamic-pituitary-adrenocortical relationships in various adrenocortical syndromes.
  • Clinical Findings
  • A. Symptoms and Signs (Figures 31-3 and 31-4)
  • Figure 31-2. Left: Histologic appearance of a typical benign adenoma of the adrenal cortex made up of a large number of identical cells from the zona fasciculata removed from a 39-year-old woman with Cushing's syndrome. Right: Section of an adenocarcinoma removed from a 36-year-old woman with metastatic adenocarcinoma showing significant pleomorphism of the cells. Invasion of a large vein is not shown in this micrograph. Note that benign adenomas will occasionally have this appearance but without invasion of the bloodstream. (Reproduced, with permission, from Forsham PH: The adrenal cortex. In: Williams RH [ed.] Textbook of Endocrinology. 4th ed. Saunders, 1968.)
  • B. Laboratory Findings
  • Figure 31-3. Drawing of a typical case of Cushing's syndrome showing the principal clinical features. (Reproduced, with permission, from Forsham PH: The adrenal cortex. In: Williams RH [ed.] Textbook of Endocrinology, 4th ed. Saunders, 1968.)
  • Figure 31-4. A patient with Cushing's disease. Note the red moon face, receding hairline, buffalo hump over the seventh vertebra, protuberant abdomen, and inappropriately thin arms and legs.
  • C. X-Ray Findings and Special Examinations
  • Figure 31-5. Noncontrast CT image of a right benign adrenal adenoma. Hounsfield units under 10. (Image courtesy of Fergus Coakley, MD, UCSF Radiology Department.)
  • Treatment
  • A. Cushing's Disease
  • B. Ectopic ACTH Syndrome
  • Figure 31-6. Contrast CT image of a left adrenocortical carcinoma. Note the irregular border and small satellite masses medially. (Image courtesy of Fergus Coakley, MD, UCSF Radiology Department.)
  • C. Total Bilateral Adrenalectomy
  • D. Adrenal Adenoma and Adenocarcinoma
  • E. Medical Therapy
  • Prognosis
  • ADRENAL ANDROGENIC SYNDROMES
  • Pathophysiology
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • C. X-Ray Findings
  • D. CT Scans
  • Treatment
  • Prognosis
  • THE HYPERTENSIVE, HYPOKALEMIC SYNDROME (PRIMARY ALDOSTERONISM)
  • Pathophysiology
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • Figure 31-7. A typical canary yellow aldosteronoma associated with the syndrome of hypertension, hypokalemia, and alkalosis. Note the relatively small size of this tumor compared with other types of adrenocortical tumors.
  • C. Localization
  • Differential Diagnosis
  • Treatment
  • A. Aldosteronoma
  • B. Bilateral Nodular Hyperplasia
  • C. Medical Treatment
  • Prognosis
  • DISEASES OF THE ADRENAL MEDULLA
  • PHEOCHROMOCYTOMA
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Biochemical Diagnosis
  • Table 31-1. 24-Hour urine measurements in patients with pheochromocytoma.
  • Tumor Localization
  • Table 31-2. Catecholamines in urine and plasma.
  • Figure 31-8. A typical large pheochromocytoma. Removal was followed by complete remission of hypertension.
  • A. CT Scans
  • B. MRI
  • C. MIBG Scanning
  • Diagnostic Strategy
  • Therapy
  • A. Preoperative Management
  • B. Surgery
  • Malignant Pheochromocytoma
  • Prognosis
  • INCIDENTALOMA
  • Metabolic Evaluation
  • Table 31-3. Differential diagnosis of adrenal incidentaloma.
  • Imaging
  • Figure 31-9. A large right adrenal myelolipoma. Note the similar CT density to perinephric and subcutaneous fat. (Image courtesy of Fergus Coakley, MD, UCSF Radiology Department.)
  • Figure 31-10. In-phase (A) and out-of-phase (B) coronal MRI of a patient with bilateral benign nonfunctional adrenal adenomas. (Image courtesy of Fergus Coakley, MD, UCSF Radiology Department.)
  • Diagnostic Algorithm
  • NEUROBLASTOMA
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • Differential Diagnosis
  • Treatment
  • Prognosis
  • BIBLIOGRAPHY
  • General
  • Cushing's Syndrome and Adrenocortical Tumors
  • Adrenal Androgenic Syndromes
  • Primary Aldosteronism
  • Pheochromocytoma
  • Incidentaloma
  • Neuroblastoma
  • 32 Disorders of the Kidneys
  • CONGENITAL ANOMALIES OF THE KIDNEYS
  • AGENESIS
  • HYPOPLASIA
  • SUPERNUMERARY KIDNEYS
  • DYSPLASIA AND MULTICYSTIC KIDNEY
  • ADULT POLYCYSTIC KIDNEY DISEASE
  • Etiology and Pathogenesis
  • Pathology
  • Figure 32-1. Polycystic kidney. Multiple cysts deep in the parenchyma and on the surface. Note distortion of the calyces by the cysts.
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • E. CT Scanning
  • F. Isotope Studies
  • G. Ultrasonography
  • H. Instrumental Examination
  • Differential Diagnosis
  • Complications
  • Figure 32-2. Simple cyst. Upper left: Large cyst displacing lower pole laterally. Upper right: Section of kidney showing one large and a few small cysts. Lower left: Excretory urogram showing soft-tissue mass in upper pole of right kidney. Elongation and distortion of upper calyces by cyst. Lower right: Infusion nephrotomogram showing large cyst in upper renal pole distorting upper calyces and dislocating upper portion of kidney laterally.
  • Treatment
  • A. General Measures
  • B. Surgery
  • C. Treatment of Complications
  • Prognosis
  • SIMPLE (SOLITARY) CYST
  • Etiology and Pathogenesis
  • Figure 32-3. Left renal cyst. Left: Computed tomography (CT) scan shows a homogeneous low-density mass (C) arising from anterior border of left kidney just posterior to tail of the pancreas. The CT attenuation value was similar to that of water, indicating a simple renal cyst. Right: After intravenous injection of contrast material, the mass did not increase in attenuation value, adding further confirmatory evidence of its benign cystic nature.
  • Pathology
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. CT Scanning
  • E. Renal Ultrasonography
  • F. Isotope Scanning
  • G. Percutaneous Cyst Aspiration with Cystography
  • Differential Diagnosis
  • Complications (Rare)
  • Treatment
  • A. Specific Measures
  • B. Treatment of Complications
  • Prognosis
  • RENAL FUSION
  • Etiology and Pathogenesis
  • Pathology (Figure 32-4)
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. X-Ray Findings
  • Differential Diagnosis
  • Complications
  • Treatment
  • Figure 32-4. Renal fusion. Upper left: Crossed renal ectopy with fusion. The renal mass lies in the left flank. The right ureter must cross over the midline. Upper right: Example of "sigmoid" kidney. Lower left: Horseshoe kidney. Pelves are anterior. Note the aberrant artery obstructing the left ureter and the low position of renal mass. Lower right: Pelvic kidney. Pelves are placed anteriorly. Note the aberrant blood supply.
  • Prognosis
  • ECTOPIC KIDNEY
  • Simple Ectopy
  • CROSSED ECTOPY WITHOUT FUSION
  • ABNORMAL ROTATION
  • MEDULLARY SPONGE KIDNEY (CYSTIC DILATATION OF THE RENAL COLLECTING TUBULES)
  • ABNORMALITIES OF RENAL VESSELS
  • ACQUIRED LESIONS OF THE KIDNEYS
  • ANEURYSM OF THE RENAL ARTERY
  • Figure 32-5. Medullary sponge kidneys. Left: Plain film of right kidney showing multiple small stones in its mid portion. Right: Excretory urogram showing relationship of calculi to calyces. Typically, the calyces are large; the stones are located in the dilated collecting tubules.
  • RENAL INFARCTS
  • Figure 32-6. Intrarenal aneurysm of renal artery. Left: Plain film showing calcified structure over right renal shadow. Right: Excretory urogram relating calcific mass to pelvis and upper calyx. (Courtesy of CD King.)
  • THROMBOSIS OF THE RENAL VEIN
  • Figure 32-7. Thrombosis of renal vein. Selective left renal venogram showing almost complete occlusion of vein. Veins to lower pole failed to fill. Note the large size of kidney.
  • ARTERIOVENOUS FISTULA
  • ARTERIOVENOUS ANEURYSM
  • Figure 32-8. Arteriovenous aneurysm. Selective renal angiogram. Note the aneurysm in center of kidney, with prompt filling of the vena cava (shown by arrows).
  • Figure 32-9. Nephroduodenal fistula and small-bowel obstruction from renal staghorn calculus. Left: Excretory urogram showing nonfunction of right kidney; staghorn stone. Right: Patient presented with symptoms and signs of bowel obstruction 4 years later. Plain film showing dilated loops of small bowel down to a point just proximal to ileocecal valve. Obstruction due to stone extruded into duodenum. (Courtesy of CD King.)
  • RENOALIMENTARY FISTULA
  • RENOBRONCHIAL FISTULA
  • BIBLIOGRAPHY
  • Congenital Anomalies of the Kidneys
  • General
  • Agenesis
  • Hypoplasia
  • Dysplasia and Multicystic Kidney
  • Adult Polycystic Kidney Disease
  • Simple (Solitary) Cyst
  • Acquired Lesions of the Kidneys
  • General
  • Infection-Related Renal Disorders
  • Aneurysm of the Renal Artery
  • Thrombosis of the Renal Vein
  • 33 Diagnosis of Medical Renal Diseases
  • MEDICAL RENAL DISEASE—OVERVIEW
  • History and Examination
  • A. Family History
  • B. Past History
  • Physical Examination
  • Laboratory Findings
  • A. Urinalysis
  • Figure 33-1. This graph illustrates the relation between total 24-hour urinary protein excretion and the total protein-to-creatinine ratio (mg/mg) determined on a random urine specimen. Although there appears to be a close correlation, there can be wide variability in 24-hour protein excretion at a given total protein-to-creatinine ratio. At a ratio of 2, for example, 24-hour protein excretion varied from 2 to almost 8 g/d. (Data from Ginsberg JM et al: N Engl J Med 1983;309:1543.)
  • B. Other Findings
  • Examination of the Kidneys and Urinary Tract
  • Renal Biopsy
  • GLOMERULONEPHRITIS
  • Immunologic Mechanisms Likely
  • A. Subepithelial Immune Deposits
  • B. Subendothelial Immune Deposits
  • C. Mesangial Immune Deposits
  • D. Anti-GBM Disease
  • Immunologic Mechanisms Not Clearly Established
  • Poststreptococcal Glomerulonephritis
  • A. Essentials of Diagnosis
  • B. General Considerations
  • C. Clinical Findings
  • Immunoglobulin A Nephropathy
  • Rapidly Progressive Glomerulonephritis
  • NEPHROTIC SYNDROME E
  • Essentials of Diagnosis and General Considerations
  • Minimal Glomerular Lesions
  • Focal Glomerulosclerosis
  • Membranous Nephropathy
  • Membranoproliferative Glomerulonephritis—Types I and II
  • Miscellaneous Diseases
  • Clinical Findings in Nephrosis
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • C. Differential Diagnosis
  • D. Treatment
  • E. Prognosis
  • RENAL INVOLVEMENT IN COLLAGEN DISEASES
  • DISEASES OF THE RENAL TUBULES AND INTERSTITIUM
  • Interstitial Nephritis
  • Analgesic Nephropathy
  • Uric Acid Nephropathy
  • Obstructive Uropathy
  • Kidney Diseases in Multiple Myeloma
  • HEREDITARY RENAL DISEASES
  • Chronic Hereditary Nephritis
  • Cystic Diseases of the Kidney
  • A. Polycystic Kidneys
  • Table 33-1. Ultrasonographic criteria for the diagnosis of autosomal dominant polycystic kidney disease.
  • B. Cystic Disease of the Renal Medulla
  • ANOMALIES OF THE PROXIMAL TUBULE
  • Defects of Amino Acid Reabsorption
  • A. Congenital Cystinuria
  • B. Aminoaciduria
  • C. Hepatolenticular Degeneration (Wilson's Disease)
  • D. Multiple Defects of Tubular Function (de Toni-Fanconi-Debré Syndrome)
  • E. Defects of Phosphorus and Calcium Reabsorption
  • F. Defects of Glucose Absorption (Renal Glycosuria)
  • G. Defects of Bicarbonate Reabsorption
  • ANOMALIES OF THE DISTAL TUBULE
  • Defects of Hydrogen Ion Secretion and Bicarbonate Reabsorption (Classic Renal Tubular Acidosis, Type I)
  • Excess Potassium Secretion (Potassium "Wastage" Syndrome)
  • Reduced Potassium Secretion
  • Defects of Water Absorption (Renal Diabetes Insipidus)
  • UNSPECIFIED RENAL TUBULAR ABNORMALITIES
  • BIBLIOGRAPHY
  • 34 Acute Kidney Injury & Oliguria
  • PRERENAL KIDNEY INJURY
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • Table 34-1. Causes of acute kidney injury.
  • Treatment
  • VASCULAR RENAL FAILURE
  • INTRARENAL CAUSES
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • C. X-Ray Findings
  • Figure 34-1. High power light micrograph showing an active hypercellular crescent containing fibrin, which has a bright red appearance (long arrow). Note that the severe inflammatory injury has led to fragmentation of the glomerular tuft (short arrow) and to creation of a rent in the capsule (double arrow). (Courtesy of Helmut Rennke, MD.)
  • Treatment
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings (Table 34-2)
  • Table 34-2. Intrinsic versus prerenal azotemia.
  • Treatment
  • Prognosis
  • POSTRENAL AKI
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • C. X-Ray Findings
  • D. Instrumental Examination
  • Treatment
  • BIBLIOGRAPHY
  • 35 Chronic Kidney Disease & Renal Replacement Therapy
  • OVERVIEW
  • Historical Background
  • Etiology
  • Figure 35-1. Incident ESRD patients; rates adjusted for age, gender, and race. Data on the prevalence of diabetes in the general population obtained from the CDC's Behavioral Risk Factor Surveillance System, at www.cdc.gov/brfss.
  • Clinical Findings
  • A. Symptoms and Signs
  • B. History
  • Figure 35-2. Incident ESRD patients; rates by age adjusted for gender and race; rates by race and ethnicity adjusted for age and gender.
  • C. Laboratory Findings
  • D. X-Ray Findings
  • E. Renal Biopsy
  • Treatment
  • A. Chronic Peritoneal Dialysis
  • B. Chronic Hemodialysis
  • C. Renal Transplantation
  • Figure 35-3. Number of transplants and size of active waiting list. There was a very large gap between the number of patients waiting for a transplant and the number receiving a transplant. This gap widened over the decade, meaning that the waiting times from listing to transplant continued to increase. The number of living donor transplants grew until 2004, while the number of deceased donor transplants continued to rise gradually. Source: 2008 OPTN/SRTR Annual Report, Tables 1.7, 5.1a.
  • BIBLIOGRAPHY
  • 36 Renal Transplantation
  • SELECTION AND PREPARATION OF RECIPIENTS
  • Genitourinary Tract Evaluation
  • Figure 36-1. Ten-year UNOS/OPTN.
  • A. Upper Tract Abnormalities
  • B. Lower Tract Abnormalities
  • Infection
  • A. Bacterial
  • B. Viral
  • Malignant Disease
  • Systemic and Metabolic Disease
  • Cardiovascular Status
  • Gastrointestinal Disease
  • Modifiable Risk Factors
  • A. Obesity
  • B. Smoking
  • Blood Transfusion
  • Transplant Allograft Nephrectomy
  • SELECTION OF DONORS
  • Living Donors
  • A. Directed Living Kidney Donors
  • Figure 36-2. Preemptive.
  • Table 36-1. Immunologic hierarchy of kidney donors.
  • B. Nondirected Living Kidney Donors
  • Figure 36-3. Living donor (LD) groups.
  • C. Live-Donor Paired Exchange
  • D. Live-Donor/Deceased-Donor Exchange
  • E. Altruistic Living Donors
  • F. Living-Donor Safety
  • Deceased Donors
  • A. Standard Criteria Donors
  • B. Expanded Criteria Donors
  • Table 36-2. Expanded criteria kidney donors.
  • C. Donation After Cardiac Death
  • D. Dual Transplants
  • E. Extracorporeal Renal Preservation
  • Table 36-3. Criteria for adult dual cadaveric kidney transplants.
  • The Major Histocompatibility Complex
  • A. Tissue Typing
  • B. Crossmatching
  • C. Serum Screening
  • D. Posttransplant Antibodies
  • Donor Nephrectomy for Transplantation
  • A. Living Donors
  • Table 36-4. Standard evaluation of the potential live donor.
  • B. Deceased Donors
  • Standard Renal Transplant Surgery
  • Imaging of the Transplant Kidney
  • Immediate Posttransplant Care
  • A. Hemodynamic Management
  • B. Delayed Recovery of Graft Function
  • C. Sudden Drop in Urine Output
  • Transplant Rejection
  • Figure 36-4. Chronic allograft nephropathy.
  • Immunosuppression
  • A. Chemical Immunosuppression with Small Molecules
  • B. Antilymphocyte Antibodies
  • C. Baseline Immunosuppression
  • D. Treatment of Rejection
  • Results of Kidney Transplantation
  • Table 36-5. Major factors that affect long-term graft outcome.
  • Complications of Kidney Transplantation
  • A. Surgical
  • B. Medical Complications
  • BIBLIOGRAPHY
  • 37 Disorders of the Ureter & Ureteropelvic Junction
  • CONGENITAL ANOMALIES OF THE URETER
  • URETERAL ATRESIA
  • DUPLICATION OF THE URETER
  • Figure 37-1. Duplication of the ureter. Incomplete (Y) type with hydronephrosis of lower pole of left kidney. Ureteroureteral (yo-yo) reflux can also occur and account for the radiographic appearance.
  • Figure 37-2. Duplication of the ureter. Complete duplication with reflux to lower pole of right kidney and chronic pyelonephritic scarring. Upper-pole ureter of left kidney is ectopic, and its associated renal parenchyma is often dysplastic.
  • URETEROCELE
  • Figure 37-3. Duplicated left kidney. A: Ultrasound showing marked hydronephrosis of the left upper pole (large arrow) in continuity with a large tortuous ureter. The lower pole of the kidney is well preserved (small arrows). B: 99mTc-DMSA scan showing the relative function of the different renal segments.
  • Figure 37-4. Ureterocele. Left: Orthotopic ureterocele associated with a single ureter. Right: Ureterocele associated with ureteral duplication and poor function of upper pole of kidney.
  • ECTOPIC URETERAL ORIFICE
  • Figure 37-5. Ureterocele in a girl with a duplication. A: Ultrasound showing marked hydronephrosis of the right upper pole (large arrow). The lower pole of the kidney is well preserved (small arrow). B: In contrast to an ectopic ureter, the dilated distal right ureter ends in a large ureterocele (small arrow) within the bladder (large arrow).
  • Figure 37-6. Ureterocele in a boy with a single system. A: Ultrasound showing moderate right hydronephrosis with a dilated proximal ureter. B: The right distal ureter ends in a small orthotopic ureterocele within the bladder (arrow).
  • Figure 37-7. Ectopic ureter. A: Voiding cystourethrogram in a boy showing voiding into the posterior urethra with reflux into a very dilated ureter, seen entering the prostatic urethra (arrow). B: A voiding cystourethrogram in a girl showing voiding with reflux into a very dilated ureter and continuing all the way up to a dilated lower pole of the right kidney. Note that the ureter is ectopic, entering the proximal urethra (arrow).
  • ABNORMALITIES OF URETERAL POSITION
  • Figure 37-8. Retrocaval ureter. An intravenous urogram showing the classic appearance of a J-hooking of the ureter behind the inferior vena cava (arrow).
  • OBSTRUCTION OF THE URETEROPELVIC JUNCTION
  • Figure 37-9. Congenital ureteral obstruction. Left: Right ureteropelvic junction obstruction with hydronephrosis. Right: Left ureterovesical junction obstruction (obstructed megaureter) with hydroureteronephrosis.
  • Figure 37-10. Ureteropelvic junction obstruction discovered after trauma. CT scan in an 18-year-old boy performed after abdominal trauma shows a markedly hydronephrotic right kidney (small arrows) and a urinoma due to urinary extravasation from a rupture of the renal pelvis (large arrow).
  • Figure 37-11. Ureteropelvic junction obstruction after prenatal hydronephrosis. A: An ultrasound shows marked hydronephrosis with a large renal pelvis and dilated calyces. There is some preservation of renal parenchyma (arrows). B: Images taken every 5 minutes from the 99mTc-MAG-3 diuretic renogram showing good function on the left kidney, but hydronephrosis and slow drainage from the kidney. The asterisk indicates when furosemide is given. Of note, there is no increase in drainage from the left kidney after furosemide. C: The computer calculated time/activity curves from the renogram pictures. Both kidneys have good function (high counts in the first couple of minutes). The right kidney (solid line) excretes the radioisotope rapidly. There is poor drainage of the left kidney (dotted line). D: A retrograde pyelogram demonstrates a normal ureter with obstruction at the ureteropelvic junction (arrow) and a large renal pelvis above the obstruction.
  • OBSTRUCTED MEGAURETER
  • Figure 37-12. Obstructed megaureter. Follow-up study in a 9-month-old boy with unilateral hydronephrosis detected by ultrasonography in utero. Excretory urogram shows the classic configuration of a dilated distal ureter, a less dilated proximal ureter, and blunted calyces.
  • UPPER URINARY TRACT DILATATION WITHOUT OBSTRUCTION
  • ACQUIRED DISEASES OF THE URETER
  • Figure 37-13. Upper urinary tract dilatation. Left: Three months after resection of posterior urethral valves, hydronephrosis in the right kidney has completely resolved. The left collecting system remains dilated. (Dashed lines outline kidneys.) Right: Radionuclide diuretic renography was performed to determine if there was secondary ureteropelvic or ureterovesical obstruction. Renogram demonstrates clear-cut "washout" of radionuclide following injection of furosemide (arrow). There is no significant obstruction.
  • Intrinsic Ureteral Obstruction
  • Extrinsic Ureteral Obstruction
  • RETROPERITONEAL FIBROSIS (RETROPERITONEAL FASCIITIS, CHRONIC RETROPERITONEAL FIBROPLASIA, ORMOND DISEASE)
  • Figure 37-14. Ureteral obstruction. Excretory urogram obtained 2 weeks after a radical hysterectomy shows bilateral ureteral obstruction and marked hydronephrosis on right.
  • Figure 37-15. Retroperitoneal fibrosis. Right and left kidneys of same patient as shown by excretory urography. Note medial marked obstruction. (Courtesy of JA Hutch.)
  • URETERAL OBSTRUCTION SECONDARY TO MALIGNANT DISEASE
  • BIBLIOGRAPHY
  • Congenital Anomalies of the Ureter
  • Ureteral Atresia
  • Duplication of the Ureter
  • Ureterocele
  • Ectopic Ureteral Orifice
  • Abnormalities of Ureteral Position
  • Obstruction of the Ureteropelvic Junction
  • Obstructed Megaureter
  • Upper Urinary Tract Dilatation without Obstruction
  • Acquired Diseases of the Ureter
  • Retroperitoneal Fibrosis (Retroperitoneal Fasciitis, Chronic Retroperitoneal Fibroplasia, Ormond Disease)
  • Ureteral Obstruction Secondary to Malignant Disease
  • 38 Disorders of the Bladder, Prostate, & Seminal Vesicles
  • CONGENITAL ANOMALIES OF THE BLADDER
  • Exstrophy
  • A. Signs and Symptoms
  • B. Diagnosis
  • C. Treatment
  • D. Prognosis
  • Persistent Urachus
  • Figure 38-1. Diagrams showing various types of patent urachus. Left: Complete atresia toward umbilicus but patent toward bladder. Center: Atresia on both ends leading cystic dilation in the middle. Right: Completely patent urachus with cystic dilation.
  • A. Sign and Symptoms
  • B. Diagnosis
  • C. Treatment
  • Other Bladder Anomalies
  • A. Diverticulum
  • Figure 38-2. MRI midline sagittal view of a case with adenocarcinoma of the urachus. A cord like urachus is seen connecting the bladder dome and umbilicus (arrow heads). A soft tissue mass is seen in the dome of the bladder (arrow). (Image Courtesy of Dr. Fergus Coakley.)
  • B. Bladder Ears
  • C. Megacystis
  • ACQUIRED DISEASES OF THE BLADDER
  • Interstitial Cystitis or Bladder Pain Syndrome
  • Figure 38-3. Cystogram demonstrating sliding hernia of the bladder in the inguinal canal (arrows).
  • A. Sign and Symptoms
  • B. Etiology
  • C. Diagnosis
  • D. Differential Diagnosis
  • E. Treatment
  • Table 38-1. National Institute of Diabetes and Digestive and Kidney Diseases Criteria for interstitial cystitis.
  • F. Prognosis
  • Foreign Body Inserted into the Bladder
  • Vesical Manifestations of Allergy
  • Diverticula
  • Figure 38-4. CT scan of the pelvis with contrast depicts a large bladder diverticulum filled with contrast and its orifice (arrow). (Image Courtesy of Dr. Fergus Coakley.)
  • Vesical Fistulas
  • A. Sign and Symptoms
  • Figure 38-5. Diagrams showing vesicoenteric fistula due to tumor in the sigmoid colon (left) and vesicovaginal fistula (right).
  • B. Laboratory Findings
  • C. Diagnosis
  • Figure 38-6. CT scan of a case with vesicoenteric fistula due to diverticulitis demonstrates tissue thickening of the bladder wall with adhered sigmoid colon (arrow). Free air is seen in the bladder (arrow head). (Image Courtesy of Dr. Fergus Coakley. )
  • D. Differential Diagnosis
  • E. Treatment
  • F. Prognosis
  • Pelvic Lipomatosis
  • Noninfectious Hemorrhagic Cystitis
  • A. Signs and Symptoms
  • B. Differential Diagnosis
  • C. Diagnosis
  • D. Prevention
  • Figure 38-7. Cystoscopy of a patient with gross hematuria after radiation therapy of prostate cancer reveals diffuse bleeding at the bladder neck due to radiation induced cystitis.
  • E. Treatment
  • Figure 38-8. Transrectal ultrasonography demonstrating typical utricular cyst. Transverse image at the base shows a round cyst (arrow) in the midline posterior to the urethra (left). On sagittal view, the cyst is typical teardrop shape (arrow heads) with the narrow end extends toward the urethra (right).
  • ANOMALIES OF THE PROSTATE AND SEMINAL VESICLES
  • Prostatic Cyst and Calculi
  • Figure 38-9. Typical prostatic calculi on transrectal ultrasonography are seen as curved bright lines (arrows) with acoustic shadows.
  • Anomalies of the Seminal Vesicle
  • BIBLIOGRAPHY
  • Exstrophy
  • Persistent Urachus
  • Other Bladder Anomalies
  • Interstitial Cystitis or Bladder Pain Syndrome
  • Foreign Body Inserted into the Bladder
  • Vesical Manifestations of Allergy
  • Diverticula
  • Vesical Fistulas
  • Pelvic Lipomatosis
  • Noninfectious Hemorrhagic Cystitis
  • Anomalies of the Prostate and the Seminal Vesicles
  • 39 Male Sexual Dysfunction
  • PHYSIOLOGY OF PENILE ERECTION
  • Innervation of the Penis
  • Figure 39-1. Location of cavernous nerves in relation to urethra.
  • Anatomy and Hemodynamics of Penile Erection
  • Mechanism of Penile Erection
  • Table 39-1. Phases of the erection process.a
  • Figure 39-2. Phases of penile erection (induced in monkeys via neurostimulation). Numbers correspond to phases outlined in Table 39-1. (Lower tracing = intracavernous pressure; upper tracing = flow within the internal pudendal artery.)
  • Hormones and Sexual Function
  • Figure 39-3. The mechanism of penile erection. In the flaccid state (A), the arteries, arterioles, and sinusoids are contracted. The intersinusoidal and subtunical venular plexuses are wide open, with free flow to the emissary veins. In the erect state (B), the muscles of the sinusoidal wall and the arterioles relax, allowing maximal flow to the compliant sinusoidal spaces. Most of the venules are compressed between the expanding sinusoids. Even the larger intermediary venules are sandwiched and flattened by distended sinusoids and the noncompliant tunica albuginea. This effectively reduces the venous capacity to a minimum.
  • Neurotransmitters and Pharmacology of Erection
  • Molecular Mechanism of Smooth-Muscle Contraction and Relaxation
  • Table 39-2. Agents that have been reported to induce or inhibit penile erection.
  • Signal Transduction in Penile Erection
  • Intercellular Communication
  • MALE SEXUAL DYSFUNCTION
  • EPIDEMIOLOGY
  • Table 39-3. New classification of ED recommended by the International Society for Sexual Medicine.
  • CLASSIFICATION AND PATHOGENESIS
  • Psychological Disorders
  • Neurogenic Disorders
  • Hormonal Disorders
  • Arterial Disorders
  • Cavernosal Disorders
  • Medication-Induced Erectile Dysfunction
  • Aging and Systemic Disease
  • DIAGNOSIS AND TREATMENT
  • Medical, Sexual, and Psychosocial History
  • Physical and Laboratory Examination
  • Self-Reported Questionnaires and Laboratory Investigations
  • Follow-up Strategy
  • ADVANCED TESTING FOR ERECTILE DYSFUNCTION
  • Tests for Penile Vascular Function
  • Table 39-4. Tests Suggested for Various Treatment Options.a
  • A. Combined Intracavernous Injection and Stimulation Test
  • B. Color Duplex Ultrasonography
  • Figure 39-4. Color duplex ultrasonography analysis of the arterial response to intracavernous vasodilator injection. In a man with normal vascular response (A), the peak flow velocity of the cavernous artery is 89.69 cm/s with negative diastolic wave indicating that his intracavernous pressure is higher than his diastolic blood pressure. In another man with arterial disease (B), the peak flow velocity is 21.94 cm/s with positive diastolic wave.
  • C. Cavernosometry and Cavernosography
  • D. Cavernous Arterial Occlusion Pressure
  • Figure 39-5. Cavernosography after intracavernous injection of papaverine. In a normal man (A), the cavernosogram shows opacification of the erect corpora cavernosa and nonvisualization of penile veins. In (B), the patient has a large leak through both superficial dorsal veins (arrows) to the saphenous veins (arrowheads). Film (C) shows abnormal venous drainage via the cavernous veins (solid arrow) into the preprostatic plexus (open arrow) and the internal pudendal veins (arrow-head). (Reproduced, with permission, from Lue TF, Tanagho EA: Physiology of erection and pharmacological management of impotence. J Urol 1987;137:829. By Williams & Wilkins, 1987.)
  • E. Arteriography
  • Figure 39-6. Internal iliac arteriogram in the flaccid penis (A) shows poor visualization of penile arteries, simulating occlusion (arrow). After intracavernous injection of 60 mg of papaverine (B), all the branches of the penile artery are well visualized.
  • Neurologic Tests
  • A. Biothesiometry
  • B. Bulbocavernosus Reflex Latency
  • C. Penile Thermal Sensory Testing
  • Nocturnal Penile Tumescence Test
  • Psychological Evaluation
  • NONSURGICAL TREATMENT OF ERECTILE DYSFUNCTION
  • Lifestyle Changes
  • Changing Medications
  • Psychosexual Therapy
  • Hormonal Therapy
  • Potential Adverse Effects of Testosterone Replacement
  • Oral Pharmacologic Therapy
  • A. Phosphodiesterase Inhibitors
  • B. Centrally Acting Oral Agents
  • Transurethral Therapy
  • Table 39-5. Intracavernous vasodilator injection therapy.a
  • Intracavernous Injection
  • A. Papaverine
  • B. Alprostadil (Prostaglandin E1)
  • C. Drug Combinations
  • D. Adverse Effects
  • E. Dosage and Administration
  • F. Treatment of Prolonged Erection or Priapism
  • G. Contraindications
  • Vacuum Constriction Device
  • PENILE VASCULAR SURGERY
  • PENILE PROSTHESIS
  • Table 39-6. Types of penile protheses.
  • MALE SEXUAL DYSFUNCTION INVOLVING EMISSION, EJACULATION, AND ORGASM
  • Physiology of Emission, Ejaculation, and Orgasm
  • Disorders Affecting Ejaculation, Emission, and Orgasm
  • BIBLIOGRAPHY
  • 40 Female Urology & Female Sexual Dysfunction
  • INTRODUCTION
  • ANATOMY
  • Bony Pelvis
  • Musculofascial Support
  • Figure 40-1. Orientation of the bony pelvis in an upright woman. (Reproduced, with permission, from Drake RL et al (eds): Gray's Anatomy for Students. Churchill Livingston, Philadelphia, 2005.)
  • Innervation
  • PATHOPHYSIOLOGY
  • Figure 40-2. Muscular support of the pelvis. The pubococcygeus, the puborectalis, and the iliococcygeus comprise the levator ani muscles. (Reproduced, with permission, from Walsh PC et al (eds): Campbell's Urology, 8th edn. WB Saunders, Philadelphia, 2002, p. 49.)
  • Figure 40-3. Diagram of the arcus tendineus levator ani and arcus tendineus fascia pelvis.
  • Figure 40-4. Fascial support of the urethra and vagina. (Reproduced, with permission, from Walsh PC et al (eds): Campbell's Urology, 8th edn. WB Saunders, Philadelphia, 2002, p. 1103.)
  • CLASSIFICATION
  • Figure 40-5. Comparison of various classification systems of pelvic organ prolapse. (Reproduced, with permission, from Theofrastous JP, Swift SE: The clinical evaluation of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:783.)
  • DIAGNOSIS
  • Symptoms
  • Physical Examination
  • EVALUATION
  • Figure 40-6. The pelvic organ prolapse quantification system. Aa, anterior vaginal wall 3 cm from hymen; Ba, lowest point of anterior vaginal wall prolapse; C, distance from hymen to cervix; D, distance from hymen to posterior fornix (pouch of Douglas); Ap, posterior vaginal wall 3 cm from hymen. Bp, lowest point of posterior vaginal wall prolapse; TVL, total vaginal length; GH, genital hiatus measured from midurethral meatus to posterior hymen; PB, perineal body measured from posterior hymen to midanus. (Reproduced, with permission, from Bump RC et al: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10.)
  • Cystourethrography
  • Figure 40-7. A: Example of complete vaginal prolapse (eversion) using `POPQ classification. This occurs after a hysterectomy; therefore, there is no point D. Points Aa and Ap are maximally distal. Points Ba, C, and Bp are maximally everted. B: Normal support with no vaginal wall descent. (Reproduced, with permission, from Bump RC et al: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10.)
  • Figure 40-8. Example of a cystocele. Lateral image of contrast-filled bladder extending well past the pubococ-cygeal line (line drawn from inferior edge of pubis to coccyx).
  • Ultrasonography
  • Dynamic Magnetic Resonance Imaging
  • Video Urodynamic Study
  • Figure 40-9. A: Sagittal MRI image of cystocele and enterocele. Small intestine protrudes posterior to the prolapsed bladder (white). B: Sagittal MRI image of an enterocele only. Bladder does not prolapse past the pubococcygeal line.
  • Cystourethroscopy
  • Upper Urinary Tract Evaluation
  • Laboratory Evaluations
  • TREATMENT
  • Nonsurgical Therapy
  • Surgical Repairs
  • Anterior Compartment
  • Figure 40-10. Anterior colporrhaphy. (Reproduced, with permission, from Nichols DH, Clarke-Pearson DL (ed.): Gynecologic, Obstetric, and Related Surgery. 2nd edn. Mosby, St. Louis, MOP, 2000.)
  • Apical Compartment
  • Figure 40-11. Abdominal sacrocolpopexy using a poly-propylene bridge from the sacral promontory to the vaginal apex. (Reproduced, with permission, from Biller DH, Davila GW: Vaginal vault prolapse: Identification and surgical options. Cleve Clin J Med 2005;72(Suppl 4):S12.)
  • Posterior Compartment
  • CONCLUSION
  • FEMALE SEXUAL DYSFUNCTION
  • INTRODUCTION
  • Figure 40-12. Circular female sexual response cycle of Basson. (Adapted from Basson R et al: Summary of the recommendations on sexual dysfunction in women. J Sex Med 2004;1(1):24–34.)
  • Table 40-1. Definitions of sexual dysfunction.
  • PHYSIOLOGY
  • EVALUATION
  • Table 40-2. Physical examination findings potentially relevant to sexual dysfunction.
  • TREATMENT
  • Psychological
  • Pharmacologic
  • Nonhormonal
  • Hormonal
  • RECOMMENDATIONS AND CONCLUSIONS
  • BIBLIOGRAPHY
  • Introduction
  • Anatomy
  • Pathophysiology
  • Classification
  • Diagnosis
  • Evaluation
  • Treatment
  • Sexual Dysfunction
  • Physiology
  • Evaluation
  • Management
  • 41 Disorders of the Penis & Male Urethra
  • CONGENITAL ANOMALIES OF THE PENIS
  • APENIA
  • MEGALOPENIS
  • MICROPENIS
  • ADULT PENILE SIZE
  • Table 41-1. Size of unstretched penis and testis from infancy to adulthood.
  • CONGENITAL ANOMALIES OF THE URETHRA
  • DUPLICATION OF THE URETHRA
  • URETHRAL STRICTURE
  • Table 41-2. Adult penile size: relationships among flaccid, stretched, and erect measurements.a
  • POSTERIOR URETHRAL VALVES
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • C. X-Ray Findings
  • Figure 41-1. Upper left: Retrograde urethrogram showing congenital diaphragmatic stricture. Upper right: Posterior urethral valves revealed on voiding cystourethrography. Arrow points to area of severe stenosis at distal end of prostatic urethra. Lower left: Posterior urethral valves. Patient would not void with cystography. Retrograde urethrogram showing valves (arrow). Lower right: Cystogram, same patient. Free vesicoureteral reflux and vesical trabeculation with diverticula.
  • Figure 41-2. Posterior urethral valves. Left: Dilatation of the prostatic urethra, hypertrophy of vesical wall and trigone in stage of compensation; bilateral hydroureters secondary to trigonal hypertrophy. Right: Attenuation of bladder musculature in stage of decompensation; advanced ureteral dilatation and tortuosity, usually secondary to vesicoureteral reflux.
  • D. Ultrasonography
  • E. Instrumental Examination
  • Treatment
  • Prognosis
  • ANTERIOR URETHRAL VALVES
  • URETHRORECTAL AND VESICORECTAL FISTULAS
  • HYPOSPADIAS
  • Classification
  • Clinical Findings
  • A. Symptoms and Signs
  • Figure 41-3. Hypospadias and epispadias. Upper left: Hypospadias, penoscrotal type. Redundant dorsal foreskin that is deficient ventrally; ventral chordee. Upper right: Hypospadias, midscrotal type. Chordee more marked. Penis often small. Lower left: Epispadias. Redundant ventral foreskin that is absent dorsally; severe dorsal chordee. Lower right: Traction on foreskin reveals dorsal defect.
  • B. Laboratory, X-Ray, and Endoscopic Findings
  • Differential Diagnosis
  • Treatment
  • Prognosis
  • CHORDEE WITHOUT HYPOSPADIAS
  • EPISPADIAS
  • ACQUIRED DISEASES AND DISORDERS OF THE PENIS AND MALE URETHRA
  • PRIAPISM
  • PEYRONIE'S DISEASE
  • PHIMOSIS
  • PARAPHIMOSIS
  • CIRCUMCISION
  • URETHRAL STRICTURE
  • Clinical Findings
  • A. Symptoms and Signs
  • B. Laboratory Findings
  • C. X-Ray Findings
  • D. Instrumental Examination
  • Differential Diagnosis
  • Complications
  • Treatment
  • A. Specific Measures
  • Figure 41-4. Left: Urethrogram demonstrating multiple anterior urethral strictures. Right: Voiding cystourethrogram following a patch skin graft of 14 cm in the same patient. There are no residual strictures.
  • Figure 41-5. Voiding urethrogram following repair of traumatic posterior urethral stricture. Arrow indicates that area of repair is stricture free.
  • B. Treatment of Complications
  • Prognosis
  • URETHRAL CONDYLOMATA ACUMINATA (URETHRAL WARTS)
  • STENOSIS OF THE URETHRAL MEATUS
  • PENILE PHLEBOTHROMBOSIS AND LYMPHATIC OCCLUSION
  • BIBLIOGRAPHY
  • Congenital Anomalies
  • Penis and Urethra
  • Hypospadias
  • Epispadias
  • Acquired Diseases and Disorders of the Penis and Male Urethra
  • Priapism
  • Peyronie's Disease
  • Phimosis
  • Paraphimosis
  • Circumcision
  • Urethral Stricture
  • Urethral Condylomata Acuminata (Urethral Warts)
  • Penile Phlebothrombosis and Lymphatic Occlusion
  • 42 Disorders of the Female Urethra
  • CONGENITAL ANOMALIES OF THE FEMALE URETHRA
  • DISTAL URETHRAL STENOSIS IN INFANCY AND CHILDHOOD (SPASM OF THE EXTERNAL URINARY SPHINCTER) AND DYSFUNCTIONAL VOIDING
  • LABIAL FUSION (SYNECHIA VULVAE)
  • Figure 42-1. Distal urethral stenosis with reflux spasm of voluntary urethral sphincter. Left: Voiding cystourethrogram showing bilateral vesicoureteral reflux, a wide-open vesical neck, and severe spasm of the striated urethral sphincter in the mid portion of the urethra (arrow) secondary to distal urethral stenosis. Right: Postvoiding film. The bladder is empty and the vesical neck open, but the dilated urethra contains radiopaque fluid proximal to the stenotic zone. Bacte-ria in the urethra thus can flow back into the bladder. (Courtesy of AD Amar.)
  • ACQUIRED DISEASES OF THE FEMALE URETHRA
  • ACUTE URETHRITIS
  • CHRONIC URETHRITIS
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Instrumental Examination
  • Differential Diagnosis
  • Treatment and Prognosis
  • ATROPHIC URETHRITIS
  • Clinical Findings
  • A. Symptoms
  • B. Signs
  • C. Laboratory Findings
  • D. Instrumental Examination
  • Differential Diagnosis
  • Treatment
  • Prognosis
  • URETHRAL CARUNCLE
  • Clinical Findings
  • Differential Diagnosis
  • Treatment
  • Prognosis
  • Prolapse of the Urethra
  • URETHROVAGINAL FISTULA
  • URETHRAL DIVERTICULUM
  • Figure 42-2. Urethral diverticulum containing stone. Left: Plain film showing stone. Arrows outline bladder. Right:Diverticulum filled with radiopaque fluid instilled through ureteral catheter. Bladder outlined by arrows.
  • URETHRAL STRICTURE
  • BIBLIOGRAPHY
  • Distal Urethral Stenosis
  • Labial Fusion (Synechia Vulvae)
  • Acute Urethritis
  • Chronic Urethritis
  • Atrophic Urethritis
  • Urethral Caruncle
  • Prolapse of the Urethra
  • Urethrovaginal Fistula
  • Urethral Diverticulum
  • Urethral Stricture
  • 43 Disorders of Sex Development
  • NORMAL SEXUAL DIFFERENTIATION
  • Chromosomal Sex
  • Gonadal Differentiation
  • Hormones
  • Figure 43-1. Sex-determining genes involved in testes and ovarian development.
  • Development of the Female Genitalia
  • Development of the Male External Genitalia
  • Figure 43-2. Schematic of male (Wolffian) and female (Müllerian) internal and external genital development from common origin.
  • Figure 43-3. Differentiation of the male and female external genitalia from the indifferent stage to full differentiation (8–16 weeks). (Illustrations by Dr Hiep Nguyen.)
  • Figure 43-4. Male human fetal external genitalia during gestation. A: 11 weeks. Note the urethra is open and urethral fold (uf) and groove are prominent in the transillumination view of the phallus. B: 16.5 weeks. Note the normal ventral curvature (vc) as well as the foreskin, which is almost completely formed. C: At 20 weeks' gestation, penile and urethral development looks complete, with the prepuce covering the glans and the penile curvature resolving. D: At 24 weeks, the prepuce covers the whole glans. Note the midline seam (ms). Note the progression of natural curvature to a straight phallus during development.
  • Figure 43-5. Theories of human penile urethral development. The ectodermal ingrowth theory as described in most textbooks of embryology postulates that the glanular urethra is formed by ingrowth of epidermis. More recent data support the formation of the entire urethra via endodermal differentiation alone.
  • Figure 43-6. Normal human fetal penis, 24 weeks (A–H). Transverse histologic sections show immunohistochemical localization with the neuronal marker S-100 (25x). Note localization of S-100 nerve marker (dark staining) completely surrounding the cavernous bodies up to the junction with the urethral spongiosum along the penile shaft except at the 12 o'clock position (A–D). On the proximal penis at the point where the corporeal bodies split into two (E) and continue in a lateral fashion inferior and adjacent to the pubic rami, the nerves localize to an imaginary triangular area at the 11 o'clock and 1 o'clock positions. At this point (E), the nerves reach their furthest vertical distance from the corporeal body (approximately one-half the diameter of the corporeal body) and continue (F–G) in a tighter formation at the 11 o'clock and 1 o'clock positions well away from the urethra.
  • Disorders of Sexual Differentiation
  • A. Disorders of Chromosomal Sex
  • B. Disorders of Gonadal Sex
  • C. Disorders of Phenotypic Sex
  • Figure 43-7. Normal human fetal penis, 45 weeks' gestation. Four views of a computer-generated three-dimensional reconstruction (A, side; B, front; C, side; D, back, E, front [without urethra]; F, side [without urethra]). Note the nerves along the outside of the tunica of the corporeal bodies and their absence at the 12 o'clock position. Note the impressive glandular innervation in E and F.
  • CLINICAL EVALUATION OF PATIENTS WITH AMBIGUOUS GENITALIA
  • History
  • Physical Examination
  • Table 43-1. Disorders of chromosomal sex.
  • Table 43-2. Disorders of gonadal sex.
  • Chromosomal Evaluation
  • Biochemical Evaluation
  • Radiographic Evaluation
  • Diagnostic Laparotomy or Laparoscopy
  • Figure 43-8. Clinical approach to intersex. Algorithm based on palpating gonads. Bil., bilateral; CS/11 DCS, corticosterone/deoxycortisol; DEAS, 1,3-bis[4-(diethylamino)-2-hydroxy phenyl]-2,4-dihydroxycyclobutenediylium dihydroxide, bis(inner salt); DCS/DOC, deoxycortisol costerone; def., deficiency; dehyd., dehydration; 17 OH-P, 17 hydroxy progesterone; exp. lap., exploratory laparoscopy; resist., resistance; synd., syndrome; T/DHT, testosterone/dihydrotestosterone.
  • Table 43-3. Disorders of phenotypic sex.
  • Table 43-4. Normal values for stretched penile length.
  • Sex Assignment
  • Figure 43-9. Pathway of steroid hormone biosynthesis and possible enzyme deficiencies. 3β-HSD, 3β-hydroxysteroid dehydrogenase; 21α-H, 21α-hydroxylase; 11β-H, 11β hydroxylase; 17β-HSD, 17β-hydroxysteroid dehydrogenase; 18 HAS, 18 hydroxy-aldosterone synthetase; 18 OAS, 18 oxidase-aldosterone synthetase; 5α-R, 5α reductase; 19A, 19 aromatase; StAR, steroidogenic acute regulatory protein.
  • Figure 43-10. A: Newborn sonogram revealing a uterus (Ut) behind the bladder (Bl) in a patient with congenital adrenal hyperplasia. Note the dilated vagina (Vag), the cervix (arrow), and the bladder. B: Genitogram showing a high confluence (arrow) of the urethra and vagina with a long common urogenital sinus in a patient with congenital adrenal hyperplasia. C: Schematic of possible genitogram findings: I. and II. Urogenital sinus anomalies with two openings on the perineum (common urogenital sinus and rectum). III. and IV. Cloacal anomalies with 1 perineal opening. Note the low and high confluence of the urethra, vagina, and rectum (UVR). (Modified with permission from Dr Hardy Hendron.) Genitogram showing the common urogenital sinus.
  • Practical Approach to the Diagnosis of Intersex
  • TREATMENT OF SPECIFIC DISORDERS
  • 46,XX DSD (Female Pseudohermaphrodites)
  • Figure 43-11. Algorithm for initial workup of intersex based on physical examination and karyotype.
  • Table 43-5. Differential diagnosis for a newborn with ambiguous genitalia.
  • A. Congenital Adrenal Hyperplasia
  • Figure 43-12. Differential diagnosis of patients with inappropriate pubertal development, impaired pubertal development, and infertility. Def., deficiency; devel., development; DOC, 11-deoxycorticosterone; exp. lap., exploratory laparoscopy; 17 OH-P, 17 hydroxy progesterone; synd., syndrome.
  • Figure 43-13. Patient with severe masculinization from congenital adrenal hyperplasia.
  • Table 43-6. Drugs that may induce disorder of sex development if taken during pregnancy.
  • B. Maternal Hormonal Sources of Virilization
  • 46,XY DSD (Male Pseudohermaphrodites)
  • A. Complete Androgen Insensitivity
  • B. Partial Androgen Insensitivity
  • Figure 43-14. Differential diagnosis of patients with male pseudohermaphroditism. 17α-D, 17(α)-hydroxylase; DHEA, dehydroepiandrosterone; GU, genitourinary; hCG, human chorionic gonadotropin; HSD, hydroxy-steroid dehydrogenase; LH, luteinizing hormone; StAR, steroidogenic acute regulatory protein; T/DHT, testosterone/dihydrotestosterone.
  • Figure 43-15. Partial androgen receptor defect resulting in severe hypospadias with curvature (A) and a small phallus (B).
  • Figure 43-16. Immunohistochemical localization of 5α-reductase type 2 (A–D) and the androgen receptor (AR) (E–H) in the same human fetal penis at 16.5 weeks of gestation (reduced from 25×). Note the strong expression of 5α-reductase type 2 along the urethral seam area (arrows).
  • 5α-Reductase Type 2 Deficiency
  • Figure 43-17. A patient with 5α-reductase type 2 deficiency. Note severe hypospadias with a small phallus, bifid scrotum, and visible prostatic utricle or blind-ending vaginal pouch.
  • Persistent Müllerian Duct Syndrome
  • Figure 43-18. Hernia uterine inguinale or persistent Müllerian duct syndrome. Note the presence of a fallopian tube (black arrow) and uterus attached (white arrow) to the testicular cord structures.
  • Abnormal Gonadal Function Syndromes
  • A. 45,X DSD (Turner's Syndrome)
  • B. 46,XX DSD Complete Gonadal Dysgenesis
  • C. 46,XY DSD Gonadal Dysgenesis (Swyer's Syndrome)
  • D. 45,X/46,XY DSD (Mixed Gonadal Dysgenesis)
  • Figure 43-19. Presentation of mixed gonadal dysgenesis with ambiguous genitalia and a unilateral palpable gonad on the right side.
  • E. 17β-Hydroxysteroid Dehydrogenase Deficiency
  • Figure 43-20. Finding at the time of surgical exploration in a true hermaphrodite. On the patient's right side, note the testes, and on the left, note the fallopian tube, uterus, and biopsy-proven ovary.
  • Ovotesticular DSD (True Hermaphroditism)
  • Unclassified Forms of Abnormal Sexual Development
  • A. Hypospadias
  • B. Micropenis
  • Figure 43-21. The spectrum of hypospadias, which is not an ambiguous or intersex condition. A: Anterior, where the meatus is on the inferior surface of the glans penis. B: Coronal, where the meatus is in the balanopenile furrow. C: Distal, on the distal third of the shaft. D: Penoscrotal, at the base of the shaft in front of the scrotum. E: Scrotal, on the scrotum or between the genital swellings. F: Perineal, where the meatus is behind the scrotum or genital swellings.
  • Figure 43-22. Androgen receptor (AR) expression in the human fetal penis at 16.5 weeks. A greater density of AR-positive cells is seen in the ventral portion of the urethral epithelium in the distal glans (A), midglans (B), and proximal glans (C). In the distal (E), mid (F), and proximal (G) shaft of the penis, all portions of the urethral epithelium show the same density of expression. Three-dimensional reconstruction was performed to demonstrate the urethral AR expression pattern (D). Note the weaker density of AR in the dorsal aspect of the glanular urethra.
  • Figure 43-23. Micropenis. Normal corporeal bodies are palpable within the foreskin. The urethral meatus is at a terminal position within the glans. Stretched penile length is <2.5 cm in this full-term infant.
  • Table 43-7. Etiologies of micropenis.
  • C. Cloacal and Exstrophy Anomalies
  • Figure 43-24. A: Male with cloacal exstrophy. B: Female with cloacal exstrophy. In the male, note the split scrotal appearance and the small hemiphallus (arrow). In the female, the clitoral bodies/genitalia are not visible.
  • SURGICAL MANAGEMENT OF DSD
  • CLITOROPLASTY
  • Figure 43-25. Normal human fetal clitoris at 24 weeks' gestation (40×) immunostained with the neuronal marker S-100 (dark stain). A: Clitoral hood, labia minora, and majora. B: Nerves on top of the erectile body and top of glans clitoris. C–E: Glans clitoris and erectile bodies. F–G: Lower part of glans clitoris with midline cleft. H: End of glans clitoris and vaginal introitus.
  • Figure 43-26. Normal human fetal clitoris, 24 weeks' gestation. Four views of a computer-generated three-dimensional reconstruction (A: top; B: bottom; C: back/top; D: bottom). Note the pathway of the nerves (light gray) with a paucity of nerves on the bottom of the clitoris as well as in the top midline.
  • Figure 43-27. Female external genitalia reconstruction in patients with a low confluence using a flap vaginoplasty. A: Surgical schematic of the perineum in patients with common urogenital sinus. B: The anterior flap for the vagina can be created using the phallic skin or the distal portion of the urogenital sinus. Two openings are created in the midline of the preputial skin flap to accommodate the clitoris and urethra. The preputial skin flap is then brought down and sutured to the anterior wall of the vagina. C: The completed repair. D: Alternatively, the preputial skin can be split in the midline and used for reconstruction of the vaginal introitus and the anterior vaginal wall. E: The completed repair. (Used with permission from Nguyen HT, Baskin LS: A Child with Ambiguous Genitalia. American Urological Association Patient Management Problems, Vol. 6. Decker Electronic Publishing Inc, 2002, p. 2.)
  • Figure 43-28. Partial urogenital mobilization for high urogenital sinus. A: The urogenital (UG) sinus is separated from the rectum posteriorly and the pubic bone anteriorly. B: The posterior skin flap (arrows) is assessed for length to reach the vagina. C: The confluence of the vagina and urethra (arrow) is separated. (Used with permission from Nguyen HT, Baskin LS: A Child with Ambiguous Genitalia. American Urological Association Patient Management Problems, Vol. 6. Decker Electronic Publishing Inc, 2002, p. 2.)
  • Vaginoplasty
  • Phallic Reconstruction
  • BIBLIOGRAPHY
  • 44 Male Infertility
  • MALE REPRODUCTIVE PHYSIOLOGY
  • The Hypothalamic-Pituitary-Gonadal Axis
  • A. Hormone Classification (Figure 44-1)
  • B. Feedback Loops
  • Anatomy of the Hypothalamic-Pituitary-Gonadal Axis (Figure 44-2)
  • A. Hypothalamus
  • Figure 44-1. Two kinds of hormone classes mediate intercellular communication in the reproductive hormone axis: peptide and steroid.
  • Figure 44-2. Major components of the HPG axis and recognized hormone feedback pathways. HPG, hypothalamic-pituitary-gonadal; GnRH, gonadotropin-releasing hormone; PRL, prolactin; T, testosterone; FSH, follicle-stimulating hormone; LH, luteinizing hormone; +, positive feedback; −, negative feedback.
  • Table 44-1. Substances that modulate GnRH secretion.
  • B. Anterior Pituitary
  • C. The Testis
  • SPERMATOGENESIS
  • Sertoli Cells
  • Figure 44-3. Testicular germ cell maturation from spermatogonium to spermatid.
  • Germ Cells
  • Genetics of Spermatogenesis
  • Table 44-2. Phases of the cell cycle and mitosis.
  • Figure 44-4. Changes in nuclear DNA content with mitosis and meiosis. G, growth phase; S, DNA synthesis phase; M, mitotic phase.
  • Stages of Spermatogenesis
  • Table 44-3. Essential differences between mitosis and meiosis.
  • Spermiogenesis
  • Sperm Maturation
  • FERTILIZATION
  • DIAGNOSIS OF MALE INFERTILITY
  • HISTORY
  • Table 44-4. Components of the infertility history.
  • Table 44-5. Medications associated with impaired ejaculation.
  • PHYSICAL EXAMINATION
  • Figure 44-5. Prader orchidometer for measuring testicular volume. (Reproduced, with permission, from McClure RD: Endocrine investigation and therapy. Urol Clin North Am 1987;14:471.)
  • Figure 44-6. Normal values for testicular volume in relation to age. (Redrawn and reproduced, with permission, from Zachman M et al: Testicular volume during adolescence: Cross-sectional and longitudinal studies. Helv Paediatr Acta 1974;29:61; and McClure RD: Endocrine investigation and therapy. Urol Clin North Am 1987;14:471.)
  • LABORATORY TESTING
  • Semen Analysis
  • Table 44-6. Semen analysis—minimal standards of adequacy.
  • A. Semen Collection
  • B. Physical Characteristics and Measured Variables
  • C. Computer-Assisted Semen Analysis
  • D. Semen Leukocyte Analysis
  • Table 44-7. Cells involved in leukocytospermia.
  • Table 44-8. Frequency of semen analysis findings in infertile men.
  • Adjunctive Semen Tests: Seminal Fructose and Postejaculate Urinalysis
  • Antisperm Antibody Test
  • Hypoosmotic Swelling Test
  • Sperm Penetration Assay
  • Sperm DNA Fragmentation Assay
  • Hormone Assessment
  • Table 44-9. Characteristic endocrine profiles in infertile men.
  • GENETIC TESTS
  • Chromosomal Studies
  • Cystic Fibrosis Mutation Testing
  • Y Chromosome Microdeletion Analysis
  • ADJUNCTIVE TESTS
  • Urinalysis
  • Semen Culture
  • Figure 44-7. Klinefelter syndrome. A: Note the eunuchoid habitus, female escutcheon, gynecomastia, and lack of temporal balding. B: Characteristic firm, small testes. (Reproduced, with permission, from McClure RD: Endocrine investigation and therapy. Urol Clin North Am 1987;14:471.)
  • Radiologic Testing
  • A. Scrotal Ultrasound
  • Figure 44-8. Regions of the Y chromosome that have been associated with male infertility include azoospermia factor (AZF) regions a, b, and c. The AZFc region contains the DAZ gene, one of the few true infertility genes isolated to date. TDF, testis-determining factor.
  • B. Venography
  • Table 44-10. Most common organisms in male genital infection.
  • C. Transrectal Ultrasound
  • D. Computed Tomography Scan or Magnetic Resonance Imaging of the Pelvis
  • Testis Biopsy and Vasography
  • Figure 44-9. Scrotal ultrasound. Varicoceles are imaged as tubular echo-free structures. (Reproduced, with permission, from McClure RD, Hricak H: Scrotal ultrasound in the infertile male. Detection of subclinical unilateral and bilateral varicoceles. J Urol 1986;135:711.)
  • Figure 44-10. Transrectal ultrasonography (sagittal view) in a man with low ejaculate volume and low sperm counts and motility. Ejaculatory duct cyst (white arrow); urethra (double white arrows); bladder (asterisk).
  • Figure 44-11. Algorithm for evaluation of azoospermia or no sperm in the ejaculate. CBAVD, congenital bilateral absence of the vas deferens; FSH, follicle-stimulating hormone; LH, luteinizing hormone; MRI, magnetic resonance imaging; CF, cystic fibrosis; ACTH, adrenocorticotrophic hormone; TSH, thyroid-stimulating hormone; GH, growth hormone; FNA, fine-needle aspiration. (Adapted with permission from Turek PJ. Practical approach to the diagnosis and management of male infertility. Nat Clin Pract Urol 2005;2:1.)
  • Multisite Fine-Needle Aspiration of Testes (Figure 44-12)
  • Figure 44-12. Technique of percutaneous fine-needle aspiration "mapping" for sperm in the testis. Cytologic samples are taken from various systematically sampled areas of the testis, guided by marks on the scrotum.
  • CAUSES OF MALE INFERTILITY
  • PRETESTICULAR
  • Hypothalamic Disease
  • A. Gonadotropin Deficiency (Kallmann Syndrome)
  • Table 44-11. Pretesticular causes of infertility.
  • B. Isolated Gonadotropin Deficiencies
  • C. Congenital Hypogonadotrophic Syndromes
  • Pituitary Disease
  • A. Pituitary Insufficiency
  • B. Hyperprolactinemia
  • C. Exogenous or Endogenous Hormones
  • TESTICULAR
  • Table 44-12. Testicular causes of infertility.
  • Common Genetic Causes
  • A. Y Chromosome Microdeletions
  • B. Klinefelter Syndrome
  • Other Genetic Causes and Syndromes
  • A. XX Male Syndrome
  • B. XYY Syndrome
  • C. Noonan Syndrome
  • D. Myotonic Dystrophy
  • E. Vanishing Testis Syndrome
  • F. Sertoli-Cell-Only Syndrome
  • G. Defective DNA Mismatch Repair
  • Gonadotoxins
  • A. Radiation
  • B. Drugs
  • Table 44-13. Medications associated with infertility.
  • Systemic Disease
  • A. Renal Failure
  • B. Liver Cirrhosis
  • C. Sickle Cell Disease
  • D. Diabetes Mellitus
  • Defective Androgen Activity
  • A. 5-Alpha-Reductase Deficiency
  • B. Androgen Receptor Deficiency
  • Testis Injury
  • A. Orchitis
  • B. Torsion
  • C. Trauma
  • Cryptorchidism
  • Varicocele
  • Idiopathic
  • POSTTESTICULAR (Table 44-14)
  • Reproductive Tract Obstruction
  • Table 44-14. Posttesticular causes of infertility.
  • A. Congenital Blockages
  • B. Acquired Blockages
  • C. Functional Blockages
  • Disorders of Sperm Function or Motility
  • A. Immotile Cilia Syndromes
  • B. Immunologic Infertility
  • C. Infection
  • Disorders of Coitus
  • A. Impotence
  • B. Hypospadias
  • C. Timing and Frequency
  • TREATMENT OF MALE INFERTILITY
  • SURGICAL TREATMENTS
  • Varicocele
  • Vasectomy Reversal
  • Table 44-15. Varicocele treatments: comparison of outcomes.
  • Figure 44-13. Two-layer microsurgical vasovasostomy. A: Mucosal stitches of 10–0 nylon are placed in the "back wall" of the vas lumen, incorporating mucosa and a small amount of submucosal tissue. B: The "front wall" mucosal sutures are then placed. C: Finally, serosal sutures of 9–0 nylon are placed in the outside wall of the vas deferens to complete the anastomosis. (Reproduced, with permission, from McClure RD: Microsurgery of the male reproductive system. World J Urol 1986;4:105.)
  • Ejaculatory Duct Obstruction
  • Table 44-16. Classification of ejaculatory duct obstruction by semen analysis parameters.
  • Figure 44-14. Transurethral resection of the ejaculatory ducts. A cystoscope with a resecting loop is used to remove the verumontanum and unroof, an associated obstructing cyst that has compressed and obstructed the ejaculatory ducts. (Reproduced, with permission, from Turek PJ: Seminal vesicle and ejaculatory duct surgery. In: Graham SD (ed.): Glenn's Urologic Surgery, 5th edn. Lippincott, Philadelphia, 1998.)
  • Electroejaculation
  • Sperm Retrieval
  • Table 44-17. Sources of retrieved sperm and associated reproductive technologies.
  • A. Vasal Aspiration
  • B. Epididymal Sperm Aspiration
  • C. Testis Sperm Retrieval
  • Figure 44-15. Microscopic epididymal sperm aspira-tion. A small "window" incision is made in the scrotum and held open with a small retractor. Under 20× magnifi-cation, the epididymis is dissected, and a single epididy-mal tubule is incised with microscissors. Fluid containing sperm is aspirated for use with in vitro fertilization.
  • Orchidopexy
  • Pituitary Ablation
  • NONSURGICAL TREATMENTS
  • Specific Therapy
  • A. Leukocytospermia
  • B. Coital Therapy
  • C. Immunologic Infertility
  • D. Medical Therapies
  • Empiric Medical Therapy
  • A. Clomiphene Citrate
  • B. Antioxidant Therapy
  • ASSISTED REPRODUCTIVE TECHNOLOGIES
  • Intrauterine Insemination
  • In Vitro Fertilization and ICSI (Figure 44-16)
  • Figure 44-16. The intracytoplasmic sperm injection pro-cedure. (Top) A mature oocyte (left) is readied for injection with a sperm (arrow) in a micropipet under the micro-scope. (Bottom) The micropipet is placed directly into the oocyte, and the sperm is deposited into the cytoplasm.
  • Preimplantation Genetic Diagnosis
  • Nonreproductive Implications of Male Infertility
  • BIBLIOGRAPHY
  • Male Reproductive Physiology
  • Diagnosis of Male Infertility
  • Causes of Male Infertility—Pretesticular
  • Causes of Male Infertility—Testicular
  • Causes of Male Infertility—Posttesticular
  • Genetic Causes of Male Infertility
  • Treatment of Male Infertility
  • 45 The Aging Male
  • INTRODUCTION
  • EPIDEMIOLOGY
  • CHANGES IN TESTIS BIOLOGY WITH AGE
  • The Endocrine Testis
  • A. Leydig Cells
  • B. Testosterone
  • Figure 45-1. Relative amounts of various forms of testosterone in the blood. Albumin-bound testosterone is considered "bioavailable" and has physiologic activity, but the SHBG-bound testosterone is chemically unavailable. SHBG, sex hormone-binding globulin.
  • The Exocrine Testis
  • A. Sertoli Cells
  • Figure 45-2. Diagram outlining the various forms of testosterone in the blood. Total testosterone includes all forms of the hormone, both free and bound. The affinity of sex hormone-binding globulin (SHBG) for testosterone is much higher (thick arrow) than that of albumin. Available forms of testosterone that exert physiologic activity include free and albumin-bound fractions. T, testosterone.
  • Figure 45-3. Changes in sex hormone-binding globulin (SHBG) with age. Although total testosterone levels may be similar in younger and older men, there is less "available" testosterone due to an increase in SHBG with age. T, testosterone.
  • SPERMATOGENESIS
  • Production
  • Table 45-1. Comparison of Sertoli cells and germ cells in younger and older men.
  • Table 45-2. Age-related changes in seminiferous tubules and sperm production.
  • Semen Quality
  • Fertility
  • Genetics
  • A. Sperm Chromosomal Anomalies
  • Figure 45-4. Incidence of sperm chromosomal structural anomalies by paternal age. (Data from Martin RH, Rademaker AW: The effect of age on the frequency of sperm chromosomal abnormalities in normal men. Am J Hum Genet 1987;41:484.)
  • B. Sperm Genetic Mutations
  • Table 45-3. selected genetic disorders associated with advanced paternal age.
  • C. Paternal Age and Birth Defects and Disease in Offspring
  • THE DIAGNOSIS OF ANDROGEN DEFICIENCY
  • Organ System Effects of Testosterone
  • Table 45-4. Testosterone effects in the normal male.
  • Patient History and Examination
  • A. Symptoms
  • B. Signs
  • Laboratory Findings
  • Figure 45-5. Algorithm for the laboratory diagnosis of androgen deficiency in the male. T, testosterone; LH, luteinizing hormone; FSH, follicle-stimulating hormone; TRUS Bx, transrectal ultrasound and prostate biopsy; MRI, magnetic resonance imaging; CT, computed tomography scan.
  • Radiological Testing
  • TREATMENT OF ANDROGEN DEFICIENCY
  • Formulations
  • Table 45-5. Types of testosterone replacement therapy available in the United States.
  • Risks
  • Contraindications and Precautions
  • Monitoring Treatment
  • Table 45-6. Patient monitoring before and during testosterone treatment.
  • FUTURE TREATMENTS FOR ANDROGEN DEFICIENCY
  • 5α-Dihydrotestosterone
  • Selective Androgen Receptor Modulators
  • Selective Estrogen Receptor Modulators
  • Human Chorionic Gonadotropin
  • 7α-methyl-19-nortestosterone
  • Dehydroepiandrosterone
  • BIBLIOGRAPHY
  • Changes in Testis Biology with Age
  • The Diagnosis of Androgen Deficiency
  • Back Matter
  • Appendix Normal Laboratory Values*
  • HEMATOLOGY
  • BLOOD, PLASMA, OR SERUM CHEMICAL CONSTITUENTS (Values vary with method used)
  • HORMONES, SERUM, OR PLASMA
  • NORMAL CEREBROSPINAL FLUID VALUES
  • RENAL FUNCTION TESTS
  • MISCELLANEOUS NORMAL VALUES
  • Index