Chapter 25

Urologic Surgery

Hunter Wessells

Bruce L. Dalkin

I Urinary Tract Infections

A Definitions

Bacteriuria is the presence of bacteria in the bladder. It can occur with or without pyuria and can be symptomatic or asymptomatic.

Pyelonephritis is a clinical syndrome with fever, chills, and flank pain accompanied by bacteriuria and pyuria.

Cystitis is an inflammatory condition of the bladder. It can be bacterial or nonbacterial (e.g., radiation, interstitial, fungal causes).

Reinfection signifies recurrent infection with different bacteria from outside the urinary tract.

Relapse indicates recurrent infection caused by the same bacterial strain from a focus within the urinary tract.

Prophylactic antimicrobial therapy refers to prevention of reinfection of the urinary tract by administration of antimicrobial therapy.

Suppressive antimicrobial therapy is used to suppress an existing urinary tract infection (UTI) that cannot be eradicated.

B Etiology

Ascending infection. Most UTIs are thought to result from ascending colonization from the introitus in women or from the periurethral area in men. Fecal flora are the most common pathogens, including Escherichia coli , other gram -negative rods, and entercocci. Other pathogens include staphycoccal species.

Incidence. UTIs are more common in women than in men, possibly because women have a shorter urethra. There may also be a protective effect of the prostatic urethra in men. Newer concepts of bacterial adherence factors in the bladder are being investigated.

C Clinical presentation

Cystitis symptoms include:

Urinary frequency

Urgency

Dysuria

Cloudy or foul -smelling urine

Hematuria

Pyelonephritis symptoms include all of the symptoms of cystitis plus fever, chills, and flank pain.

DDiagnosis

Urinalysis

Pyuria. The presence of white blood cells in the urine indicates inflammation.

Bacteriuria. The detection of bacteria in the urine may require a Gram stain.

Nitrate reduction. Nitrate in the urine is reduced to nitrite in the presence of bacteria.

Leukocyte esterase. White blood cells contain esterases that can be detected in the urine.

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Urine culture is performed on a split agar disposable plate and determines the presence of bacteria in the

urine. The common quantization for infection is ≥10 - 5 bacteria. However, lower numbers present in symptomatic patients may signify infection.

E Treatment

Choice of antimicrobial agent

Uncomplicated cystitis. Good results have been obtained with ampicillin, amoxicillin, first -generation cephalosporins, fluoroquinolones, nitrofurantoin, and trimethoprim-sulfamethoxazole. Regional differences in antibiotic resistance exist and should dictate choice of antimicrobial agent.

Complicated UTI. Fluoroquinolones or parenteral regimens are recommended for initial empirical therapy of a UTI associated with significant anatomic or structural abnormality of the urinary tract or with acute pyelonephritis or prostatitis.

Duration of therapy

Uncomplicated cystitis therapy lasts for 1–3 days.

Complicated UTI therapy lasts for 7–14 days.

Acute prostatitis therapy is given over 14–28 days.

Pyelonephritis therapy lasts for 14–21 days.

F Serious complications of a UTI

Renal papillary necrosis. Sloughing of the renal papillae is frequently seen in diabetic patients. This sloughing can cause ureteral obstruction and hydronephrosis.

Pyonephrosis is infected hydronephrosis associated with infectious destruction of renal parenchyma. Usually, the patient is very ill and has a fever and chills.

Cause. Obstruction (e.g., ureteral calculus) with infection

Treatment

Ureteral catheter drainage

Percutaneous nephrostomy tube, if a ureteral catheter is not possible

Perinephric abscess is thought to occur usually from renal extension of ascending infection.

Clinical presentation varies among patients.

Fever, chills, and flank pain are common.

Symptoms may persist after appropriate antimicrobial therapy.

Diagnosis. Ultrasound and computed tomography (CT) scan are the best methods.

Treatment can include the following:

Percutaneous aspiration and drainage

Relieving obstruction if present (e.g., removal of a ureteral catheter)

Antimicrobial therapy

G Prostatitis/Chronic pelvic pain syndrome is a spectrum of infectious and noninfectious diseases of the prostate gland

Clinical presentation includes urinary frequency, urgency, perineal pain or fullness, and dysuria.

Subsets include acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia (Table 25 -1).

Diagnosis

Acute bacterial prostatitis presents with most of the aforementioned symptoms plus a fever. Prostatic massage should not be performed to avoid bacteremia.

Urinalysis. Patients with acute bacterial prostatitis usually have inflammatory findings on urinalysis.

Expressed prostatic secretions (EPS) , which are fluid obtained by digital massage of the prostate, are tested for leukocytes in chronic inflammatory conditions.

Bacteriologic etiology

Young men (younger than 50 years of age). Chlamydia and gram -negative organisms predominate.

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TABLE 25-1 Diagnostic Features of Prostatitis/Chronic Pelvic Pain Syndrome

WBC, white blood cell count; EPS, expressed prostatic secretions.

Elderly men (older than 50 years of age). Gram-negative organisms are the most common pathogens.

Treatment

Acute bacterial prostatitis

Trimethoprim-sulfamethoxazole for 30 days

Fluoroquinolone for 30 days

Parenteral therapy with ampicillin and gentamicin or vancomycin, if the patient is systemically ill or has a complicated UTI

Chronic bacterial prostatitis. Treatment is based on culture and sensitivity.

Trimethoprim-sulfamethoxazole for 6 weeks

Fluoroquinolone for 6 weeks

To treat symptomatic episodes or to consider suppression if therapy is ineffective (which it commonly is)

Nonbacterial prostatitis

Doxycycline for 4–6 weeks

Symptomatic control, including sitz baths

Prostatodynia. Because the cause may be multifactorial and include poorly understood, treatment is evolving.

Symptomatic control with empirical antimicrobial therapy

α-Adrenergic antagonists

Trycyclic antidepressents or membrance stabilizing agent (e.g. gabapentin)

Muscle relaxants (e.g., diazepam)

Biofeedback

Stress reduction techniques

Saw Palmetto and Pygeum extracts; anti -irritants to the prostate

II Urinary Calculi

A Etiologic theories

Supersaturation and crystallization

Uric acid and cystine calculi form when urine with an acid pH less than 6.0 becomes oversaturated with uric acid or cystine.

Struvite (magnesium ammonium phosphate) calculi form when the magnesium ammonium phosphate ions exist in an alkaline urine.

Inhibitor deficiency. Inhibitors (e.g., high molecular weight glycoproteins, citrate, magnesium, phosphates [pyrophosphate], zinc) that exist in the urine and can retard stone formation may be lacking.

B Types of urinary calculi

Calcium oxalate calculi are the most common stones. They are radiopaque owing to the calcium ion. They exist in monohydrate (more radiodense) and dihydrate forms.

Uric acid calculi are radiolucent stones that are formed from excess urinary uric acid levels.

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Cystine calculi are faintly radiopaque because of the sulfur ion.

Cause. Cystinuria is an autosomal recessive disorder that results in a defect in renal tubular reabsorption of four amino acids: cystine, ornithine, arginine, and lysine. Only cystine forms calculi.

Heterozygotes will most likely not form calculi; homozygotes invariably form multiple calculi.

Cystine calculi form because of the low solubility of cystine in urine with a pH less than 7.0.

Prevention. Overhydration and urine alkalinization to pH 7.5 are the most effective preventive measures. Oral cystine-binding drugs, such as D-penicillamine or α-mercaptopropionylglycine, also help to prevent stone formation.

Treatment of existing stones is usually multimodal with percutaneous procedures, extracorporeal shock -wave lithotripsy (ESWL), and dissolution therapy (percutaneous). Dissolution solutions include N-acetylcysteine or bicarbonate.

Struvite calculi are also radiopaque. They are usually related to chronic UTIs with urea -splitting bacteria, which maintain an alkaline urine:

Proteus, which is most common

Providencia

Pseudomonas

Klebsiella

C Clinical presentation

The most frequent symptom is pain, which is caused by ureteral obstruction. The site of pain is related to the location of the obstructing calculus (e.g., flank pain, lower abdominal pain, testicular pain, or vulvar pain). Other symptoms that can occur include:

Hematuria (visible or microscopic)

Nausea and vomiting

Irritative bladder symptoms (e.g., from a ureterovesical junction calculus)

D Diagnosis

Physical examination. Patients are usually in distress and have costovertebral angle tenderness. Occasionally, an associated paralytic ileus can occur, which must be differentiated from an acute abdomen.

Urinalysis

Hematuria is usually present.

A uric acid stone is unlikely to be found in a patient with a urine pH of 6.5 or higher.

Noncontrast spiral computed tomography (CT) is now the diagnostic test of choice. This procedure is less costly, less time consuming, without contrast and is very accurate; however, although improvements are being made, it is not yet as informative as intravenous pyelography (IVP).

Excretory urography (IVP) can be useful to delineate complex anatomy or as alternative to CT (Fig. 25 -1).

Renal function should be assessed before IVP to avoid contrast nephrotoxicity.

IVP should define stone size, location, and degree of obstruction.

Ultrasonography is best used in patients with elevated serum creatinine or with a severe allergy to contrast media. It defines hydronephrosis or an acoustic shadow from a calculus. Ultrasonography is often used in conjunction with a plain abdominal radiograph.

Cystourethroscopy and retrograde pyelography may need to be used to confirm the presence of a calculus and reveal its location if it is difficult to identify the calculus on imaging studies.

E Treatment

Indications for emergency surgery include:

Fever. Obstructive calculi in a patient with a fever requires emergent decompression of the obstructed system. This is best accomplished through cystoscopy and retrograde placement of a ureteral catheter or stent. No further manipulation of the calculus should be performed

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at that time because of the risk of sepsis. If the obstructed system is unable to be decompressed in this manner, a percutaneous nephrostomy tube should be placed.

FIGURE 25-1 IVP; preliminary film (left) reveals a radiointensity (right) between L2 and L3. After injection of intravenous contrast, the density is seen obviously in the proximal ureter with resultant hydrouteronephrosis.

Renal insufficiency. An elevated serum creatinine level or ureteral calculi requires urgent ultrasonography. Similarly, cystoscopy with retrograde pyelography can further delineate an anatomic problem, and stent placement may be necessary. A classic situation is the solitary kidney with an obstructing calculus.

Observation for spontaneous stone passage

The patient must have adequate pain control (orally), an ability to take liquids by mouth, and a stone that has a favorable chance of passing.

The likelihood of spontaneous passage is related to the size of the stone and the site of obstruction. Most distal ureteral calculi of 5 mm or less will pass spontaneously.

Surgical procedures. Advances in endoscopic techniques, ESWL, and endourology successfully allow most calculi to be removed without open surgical procedures.

Indications for intervention include:

Severe pain

Nonprogression of calculus passage

Infection (emergent)

Prolonged obstruction

Interference with lifestyle

Percutaneous nephrostomy procedures allow renal calculi to be approached through a nephrostomy tube tract in the flank. This is best suited for large calculi that can be fragmented and removed using ultrasonic, electrohydraulic, or laser lithotriptors.

Ureteroscopic procedures. A transurethral approach into the ureter is best for calculi in the distal half of the ureter but may also be used for upper ureteral and renal calculi.

Calculi can be “grabbed” in a wire basket and removed intact, or laser, electrohydraulic, or ultrasonic lithotriptors may be used to fragment calculi.

A stent is often left in the ureter after manipulation to alleviate obstruction from edema.

ESWL can be used for renal or ureteral calculi. It consists of an external energy source, which is focused by fluoroscopic or ultrasound guidance on a calculus to provide a high-pressure zone that can fragment the calculus. The gravel-like fragments pass through the ureter.

Complications include bleeding, perinephric hematoma, “steinstrasse” (gravel causing ureteral obstruction), and hypertension.

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Contraindications include coagulopathy, antiplatelet medications, or infection. Simultaneous bilateral treatment is contraindicated.

F Metabolic evaluation and prophylaxis

Patients who require a metabolic evaluation to determine the etiology of their calculus formation include young people (younger than 40 years of age) experiencing their first calculus event, people with multiple calculi, and people with recurrent stone formation. Most of these patients will have a metabolic abnormality that can be benefited by medical therapy. All patients require radiographic assessment to rule out anatomic causes for calculi formation, such as obstruction with urinary stasis.

G Analysis of calculi

The retrieved calculus or fragments should be analyzed to determine their composition.

Calcium-containing calculi consist mainly of calcium oxalate or calcium phosphate.

Serum chemistry, urinalysis, and 24 -hour urine collection for calcium, oxalate, phosphate, uric acid, citrate, and creatinine are performed.

The goal is to differentiate the various causes of calcium stone formation , such as:

Renal hypercalciuria (leak of renal calcium)

Absorptive hypercalcuria (excessive gastrointestinal absorption of calcium)

Hyperparathyroidism

Normocalciuria

Renal tubular acidosis (in association with sarcoidosis, hypercalcemia, vitamin D intoxication, immobilization syndrome)

Treatment for calcium-containing calculi includes:

Hydration to maintain a urine output greater than 2 L/day

Thiazide diuretics for renal hypercalcuria

Orthophosphates (absorptive hypercalcemics) to bind calcium in the gastrointestinal tract

Citrate to increase urinary citrate, which is an inhibitor of calculus formation

Low-calcium diet

Struvite calculi require the presence of urea -splitting bacteria, which maintain an alkaline urine environment.

Proteus is the most common pathogen.

Treatment. Removal of all stone fragments plus eradication of infection is imperative. Frequently, the patient requires a combination of percutaneous and ESWL treatment. Percutaneous dissolution therapy is sometimes used on remaining small fragments.

Uric acid calculi are radiolucent on plain radiographs and dense (white) on a CT scan. They form in acid urine pH (i.e., pH <6.0). Alkalinization of urine to pH 7.0 will dissolve uric acid calculi. Potassium citrate or sodium bicarbonate is also effective. If hyperuricemia is present, allopurinol should be added for prevention of future calculi.

Cystine calculi (see II B 3)

III Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland that occurs commonly in aging men. Histologic changes include stromal and epithelial hyperplasia in the transition (periurethral) zone, which can compress the prostatic urethra and obstruct urinary flow. This process depends on testosterone, but the exact etiology remains unknown. The clinical sequela of BPH, lower urinary tract symptom (LUTS) , occur in only a subset of patients with histologic BPH. Obstruction is thought to have a static component (mechanical) and a dynamic component (bladder neck, prostatic capsule, and urethral tone).

A

Diagnosis is based on the patient's symptoms and findings on digital rectal examination (DRE). Cold weather, ingestion of alcohol, narcotics, antihistamines, anticholinergics, and holding urine for prolonged periods may exacerbate symptoms or precipitate urinary retention.

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Symptoms

Obstructive voiding symptoms of BPH. These symptoms tend to respond best to treatment.

Diminished force of urinary stream despite a full bladder

Hesitancy in initiating flow

Sense of incomplete emptying

Intermittency or “double voiding”

Urinary retention

Irritative voiding symptoms. These are thought to be caused by detrusor instability from chronic obstruction.

Frequency

Urgency, possibly urge incontinence

Nocturia

Dysuria

The International Prostate Symptom Score is a seven -item validated questionnaire that is useful to quantify severity of LUTS. Scores range from 0 to 35 and are subdivided into Mild (0– 7), Moderate (8–19), and Severe (19–35).

Physical examination and diagnostic testing include:

Palpation of the gland to assess size, consistency, and presence or absence of induration (risk of cancer)

Palpation of a suprapubic mass consistent with a full bladder

Hematuria (microscopic or gross)

Prostatic-specific antigen (PSA) (optimal)

Assessment of residual urine volume via transabdominal ultrasonography or direct catheterization

Uroflowmetric findings of diminished flow rate and prolonged voiding, or urodynamic evidence of low flow rate despite high intravesical pressure Optional Additional Tests

Cystourethroscopy to assess visual obstruction, bladder trabeculation, cellule or diverticuli formation, or bladder calculi. (None of these findings is specific for BPH, and each can be present in the absence of significant symptoms.)

Transrectal ultrasonography (TRUS) to demonstrate enlargement and allow estimation of the volume of prostatic tissue, and biopsy if a significant risk of cancer exists

IVP to demonstrate an enlarged prostatic impression on the inferior bladder, bladder wall thickening, hydroureteronephrosis, “J hooking” of the distal ureters, or bladder calculi. (IVP is no longer a standard part of the evaluation but may be included if infection or hematuria is present.)

B Treatment

Indications for treatment. Absolute indications for intervention include:

Urinary retention

Significant or recurrent gross hematuria not due to other causes.

Bladder calculi

Bilateral hydroureteronephrosis with renal insufficiency secondary to bladder outlet obstruction

Repeated UTIs caused by urinary stasis

Most men initiating treatment do so for relief of symptoms rather than any absolute indication.

Goals of treatment include:

Symptomatic improvement

Enhancement of bladder emptying and flow dynamics

Preservation of bladder and upper urinary tract function

Resolution of hematuria, if present

Therapies. Surgical treatment remains the gold standard for removing the transition zone tissue of the prostate. However, there is an increasing demand for conservative therapy driven by cost considerations and by pharmacologic and technical advances.

Surgical therapy

Transurethral resection (transurethral prostatectomy; TURP) provides reliable and immediate improvement in both symptoms and voiding dynamics. A wire loop attached

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to an electrocautery unit is used to resect tissue under direct cystoscopic vision. Complications include bleeding, infection, retrograde ejaculation, bladder neck contracture, urethral stricture, and impotence (rarely). Regional anesthesia is commonly utilized. Transurethral incision (TUI) may be appropriate for patients who have small (<20 g) glands. TUI is associated with a lower incidence of bladder neck contracture and retrograde ejaculation.

Open prostatectomy, or enucleation, is usually reserved for patients with glands larger than 60 g or in whom other pathology exists (e.g., vesical calculus or bladder diverticulum requiring repair).

Laser ablation techniques cause delayed sloughing or more immediate evaporation of obstructing tissue. Numerous laser techniques exist; the results are reasonable with the newest vaporization lasers comparable at 3 years to TURP, unlike other laser techniques. Anticoagulated patients currently represent the most appropriate candidates for this technique because bleeding complications are minimal.

Microwave therapy is a technique for men with mild to moderate symptoms with marginal efficacy.

Intraprostatic stents are available to mechanically relieve bladder outlet obstruction but have seen a declining role. Risks of infection, erosion, migration, encrustation, and severe irritative symptoms limit use to rare patients who are too ill to undergo a more definitive procedure.

Medical therapy is used to relieve symptoms in men with mild to moderate disease. Although objective improvement may be minimal, if symptomatic improvement occurs, treatment is successful.

Selective α1 -sympatholytics block α 1 -receptors in the prostatic capsule and bladder neck

area, reducing outlet resistance and improving symptoms. In men with mild to moderate symptoms of prostatism, these agents represent the most commonly used first -line treatment with fairly good symptomatic improvement. Principal side effects include orthostatic hypotension and asthenia.

5 α-Reductase inhibitors block intraprostatic conversion of testosterone to dihydrotestosterone (DHT), reducing prostatic size and improving symptoms with minimal side effects. Objective symptom improvements have been modest, and a trial of 3–6 months may

slightly be required to determine efficacy. These agents reduce the risk of acute urinary retention and the need for TURP.

Combination Therapy (e.g. 5 α-reductase inhibitor plus α-sympatholytics) has been shown in a

RCT to be superior to single -agent therapy for the prevention of disease progression.

IV Carcinoma

A Prostate tumors

Epidemiology. There is an increasing number of new cases; in the United States, blacks have a higher mortality rate compared with whites, even when the rate is adjusted for age and socioeconomic status, likely due to later presentation.

Etiology. There appears to be an increased risk in men with one or more relatives diagnosed before 70 years of age. A hormonal dependence exists but is not clarified.

Pathology. Approximately 95% of prostatic carcinomas are adenocarcinomas. Transitional cell carcinoma of the prostatic urethra, small cell carcinomas, and sarcomas are uncommon lesions.

The anatomic site of origin is most commonly the peripheral zone, which is felt on DRE. The transition zone, or periurethral zone (area removed at transurethral resection for benign disease), is the other common site of cancer.

Premalignant change. Prostatic–intraepithelial neoplasia (PIN), when high grade, is frequently associated with concomitant adenocarcinoma. Whether it is a true precursor is unknown.

Tumor grading

Grading is the histologic assessment of the metastatic potential of a tumor.

The Gleason grading system is most commonly used: Gleason grade ranges from 1 (low) to 5 (high). The Gleason sum total is derived by adding the most common and the

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second most common grades seen in the specimen; that is: 3 + 2. The sum total is subdivided as low (2–4), moderate, (5–6), and high (7–10).

Diagnosis

Present diagnostic modalities include DRE, PSA serum level, and TRUS.

DRE is a traditional method of cancer detection, assessing for induction, or a “module,” in the prostate and is a means to diagnose some cancers missed by other modalities (e.g., PSA, TRUS).

PSA level. PSA is a serine protease that serves to liquefy semen after ejaculation. It has a diagnostic role as well as a role in following response to cancer treatment. When combined with DRE, determination of the PSA level improves the ability to detect cancers. Free PSA: a subset of total TSA also providing assistance in diagnosis. A low level, <15% of total PSA, correlates with a higher risk of cancer.

TRUS is an operator-dependent technique that is marginally helpful at identifying lesions. TRUS is excellent in aiding or directing biopsies of the prostate.

T (Tumor)

N (Nodes)

N0 No regional lymph node metastases

N1 Single node, under 2 cm

N2 Single node 2–5 cm or multiple nodes <5 cm

N3 One or more nodes >5 cm

M (Distant metastases)

M0 No distant metastases

M1 Distant metastases, bone or viscera

Pelvic lymph node dissection. A routine part of radical prostatectomy to remove the obturator/iliac lymph node packet. Reasonable staging procedure (open or laparoscopically) in high-risk men, based on grade, PSA, and clinical stage, if it will alter recommended treatments.

Prostascint scan and nuclear imaging study to attempt to identify a low -volume recurrence

of cancer in men previously treated. Accuracy and clinical role are still unclear.

Treatment by stage (Table 25 -2)

Clinically localized disease (T1-T2, N0, M0)

Based on the natural history of untreated disease, men with a projected survival of longer than 7–10 years should be considered for aggressive treatment with radiation therapy or radical prostatectomy.

Radiation therapy can be delivered via external beam or radioactive seed implantation. Complications frequently include urinary urgency and frequency, hematuria, strictures, impotence, incontinence, and rectal complaints.

Radical prostatectomy via a retropubic or perineal approach is removal of the prostate, the ampullae of the vas deferens, and the seminal vesicles. The urinary bladder is reanastomosed to the membranous urethra. Complications include bleeding, impotence (30%–100%), incontinence (2%–5%), and rectal injury.

Clinical observation. Serial PSA and DRE monitoring with the use of androgen ablation therapy when disease progression occurs is best utilized in men with a lower than 7- to 10 -year projected survival, or possibly in healthy men with T1 lesions.

Locally extraprostatic disease (stage T3). There is no consensus treatment at present. Newer combination modalities include neoadjuvant androgen ablation with surgery or radiation.

Pelvic lymph node metastases. Most patients are treated by androgen ablation therapy without radiation treatment to the prostate. The possibility of removing the prostate in conjunction with androgen ablation therapy does not clearly improve survival, although it is done in some clinical centers.

Distant metastatic disease (bone, retroperitoneal lymph nodes, or other soft tissue metastases)

The standard treatment is androgen ablation therapy to lower serum testosterone. Methods of lowering testosterone include:

Bilateral scrotal orchiectomy

LHRH agonist. Injections downregulate pituitary LH production, thus lowering serum testosterone.

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Estrogens (e.g., diethylstilbestrol) create negative feedback to the pituitary to inhibit LH secretions (no longer available).

Side effects include impotence, breast enlargement and tenderness (estrogens), hot flashes, fatigue, osteoporosis, and weight gain.

Total androgen blockade

Orchiectomy or an LHRH agonist plus antiandrogen supplement

Antiandrogens are competitive inhibitors at the androgen receptor level.

Numerous studies have been done comparing standard androgen ablation with total androgen blockade, with an unclear possible survival advantage to total blockade.

Survival. Median survival with metastatic disease is 2–2.5 years. Men who have a good biochemical response (PSA nadir <4 ng/mL) have a longer survival than do men who have a poor biochemical response (PSA nadir >4 ng/mL).

Hormone refractory disease is the progression of disease after androgen ablation therapy. Survival averages 12–18 months. To date, no therapies are consistently effective, but several chemotherapy agents are approved with modest efficacy (mitoxantrone, paclitaxel [Taxol]).

B Bladder carcinoma

Epidemiology

In the United States, more than 45,000 new cases per year of bladder carcinoma were diagnosed recently, and men were more commonly affected than women.

Generally, carcinoma of the bladder is a disease of the elderly, with a median age of 67–70 years.

Etiology. Likely contributors to development of bladder carcinoma include:

Occupational exposure to aniline dyes, aromatic amines, and β-naphthylamine

Cigarette smoking

Phenacetin (analgesic) abuse

Chronic inflammation from indwelling urethral catheters, suprapubic tubes, or calculi, which can predispose to squamous cell carcinoma

Schistosoma haematobium cystitis , which also is associated with a high risk for squamous cell carcinoma

History of cyclophosphamide treatment

History of pelvic irradiation

Clinical presentation. Painless hematuria is the most common (85%) presenting symptom. Bladder irritability with urinary frequency, urgency, and dysuria is frequently associated with diffuse carcinoma in situ or invasive cancer.

Diagnosis

Urinalysis may show microscopic hematuria.

Intravenous urogram is used to evaluate the kidneys and ureters but may miss many smaller bladder lesions.

Cystourethroscopy. A thorough inspection of the bladder is required to identify the number and location of the lesions (frequently multifocal) as well as their appearance (papillary or nodular). A saline washing (bladder barbotage) can be performed, and the washings can be evaluated to identify

malignant cells.

Molecular diagnostic tests exist, but sensitivity and specificity vary, making them ineffective screening tests (BTA, NMP-22).

Pathology. Types of bladder carcinoma include:

Transitional cell carcinoma , which accounts for more than 90% of tumors in the bladder

Carcinoma in situ (CIS). Poorly differentiated transitional cell carcinoma confined to the urothelium.

Squamous cell carcinoma , which is associated with Schistosoma haematobium infection (mainly in Egypt) and in patients with chronic cystitis due to foreign bodies

Adenocarcinoma is a rare tumor that usually occurs in the dome of the bladder (urachal remnant). Rarely, it is seen in people born with exstrophy of the bladder.

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Staging is determined based on the following:

Endoscopic resection. The tumor is resected in superficial and deep components. Deep resection is performed to define muscle -invasive disease. All visible tumors should be resected. Random bladder and prostatic urethral biopsies may be performed to determine the multifocal extent of disease.

Pathologic evaluation includes grade of lesion, evidence of invasion into the lamina propria or muscle, and presence of CIS in random bladder biopsies.

Bimanual examination under anesthesia is performed after transurethral resection to evaluate extravesical spread and manual mobility of the primary lesion (e.g., pelvic side wall fixation).

The presence of muscle -invasive disease mandates metastatic evaluation and includes:

CT scan of the abdomen and pelvis to evaluate disease spread to the pelvic or para -aortic lymph chain, liver, or adrenal glands.

Chest radiograph and chest CT scan

A chest radiograph is usually adequate; indeterminate results can be evaluated by CT scan.

CT scan may be best used in patients with known intra -abdominal metastases to define possible pulmonary metastases.

Bone scans should be performed routinely to evaluate bone metastases. Serum alkaline phosphatase is a helpful marker for bony metastases but should not be used exclusively.

Staging system (Table 25 -3)

Treatment

Superficial transitional cell tumor (Ta, T1 lesions)

These tumors are treated primarily by complete transurethral resection. Serial endoscopic

and cytologic follow-up evaluation should be done at regular intervals. Approximately 70% of patients develop recurrences.

Intravesical adjuvant therapy may reduce the recurrence rate to 30%–45%.

Thiotepa (an alkylating agent)

Mitomycin C, which inhibits DNA synthesis

Doxorubicin , which inhibits DNA synthesis

TABLE 25-3 Staging Classifications of Urinary Bladder Cancer

T (Primary tumor)

N (Regional lymph nodes below aortic bifurcation)

M (Distant metastases)

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Bacillus Calmette-Guerin (BCG), which is an attenuated strain of Mycobacterium bovis that has a stimulatory effect on immune responses (probably the most effective agent for preventing a recurrence or for treating carcinoma in situ)

α-Interferon , an immune modulator

Carcinoma in situ (Tis). Intravesical BCG is the most effective agent. It is usually given in six weekly instillations, with a repeat course if a complete response (normal follow-up cystoscopy, biopsies, and cytology) is not attained.

Muscle-invasive localized disease (T2, T3, T4). The 5-year survival for organ-confined lesions is 70%–75%.

Radiation therapy is relatively ineffective, with a 20% long-term survival. Newer investigational uses of radiation therapy involve attempts at bladder preservation through combination protocols using systemic chemotherapy plus radiation therapy. Radiation therapy prior to radical cystectomy has not improved survival or decreased the incidence of local recurrence.

Radical cystectomy

In men, pelvic lymphadenectomy with cystoprostatectomy is performed. Urethrectomy is performed if there is tumor involvement of the prostatic urethra.

In women, anterior pelvic exenteration is performed, in which the bladder, urethra, uterus, fallopian tubes, ovaries, and anterior vaginal wall are removed.

Chemotherapy prior to cystectomy is a newer combination approach with debatable improvements in survival.

Urinary diversion

Conduits can be created using ileum or transverse colon. These allow urine to traverse into an external collection device on the abdominal wall.

Continent diversion involves the creation of an intra -abdominal reservoir for urine, which is drained by passing a catheter through a stoma on the abdominal wall.

Neobladder formation using the small bowel (ileum) or colon allows men to void via

FIGURE 25-3 A retrograde pyelogram reveals a large radiolucent irregular filling defect in the distal ureter with proximal hydroureteronephrosis. Ureteroscopy with biopsy confirmed a transitional cell carcinoma.

FIGURE 25-4 Left: A retrograde pyelogram reveals a large radiolucent filling defect that involves most of the renal pelvis. A computed tomography (CT) scan (right) shows this mass to be soft tissue density (not a calculus). Ureteroscopy and biopsy confirmed a transitional cell carcinoma.

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Conservative excision may be appropriate for low -grade, low -stage ureteral tumors. This involves tumor excision with primary ureteroureterostomy or ureteral reimplantation (into the bladder) for distal ureteral lesions.

Endoscopic treatment. Newer equipment has allowed for endoscopic ureteral resection of low -grade and low -stage tumors. The role is still evolving but is currently reserved for patients with low -grade, papillary tumors in solitary renal units or for patients whose health precludes major surgical intervention.

D Renal cell carcinoma

Epidemiology. There are approximately 30,000 new cases of renal cell carcinoma per year. The disease is more common in men than in women and has a peak incidence in the fifth to seventh decades of life. Renal cell carcinoma is associated with von Hippel–Lindau disease (VHL).

Etiology. There is no known specific causative agent, but smoking may be a risk factor. Cytogenetic studies most commonly show defects in chromosome 3, the locus of the VHL gene, a tumor suppressor gene.

Clinical presentation. Renal cell carcinoma is commonly discovered during radiographic studies for other complaints (incidental). The classic triad of pain, hematuria, and flank mass is very uncommon.

Paraneoplastic syndromes are uncommon but include:

Stouffer's syndrome (nonmetastatic hepatic dysfunction), which is a poor prognostic sign

Hypercalcemia, which has an unclear etiology

Hypertension, due to a local vascular phenomenon or renin secretion

Erythrocytosis , due to erythropoietin production

Endogenous pyrogen production and fevers , the cause of which are unknown

Diagnosis

Excretory urography with nephrotomography allows abnormal renal contours or extrinsic compression of the renal collecting system to be seen.

Ultrasonography is useful for differentiating a simple renal cyst from a complex or solid lesion. Criteria for a simple cyst are absence of internal echoes; a smooth, thin wall; and an acoustic shadow arising from the edges of the cyst. Any lesion that is not a simple cyst on ultrasound requires a CT evaluation.

CT scan with intravenous and oral contrast is the most cost -effective diagnostic and staging modality. It evaluates local tumor, venous extension, regional lymph nodes, and liver metastases.

MRI may be better at defining venous extension than CT scan. Its cost -effectiveness is not clear.

Renal arteriography is rarely used, being reserved for renal-sparing surgery (i.e., partial nephrectomy). Its diagnostic role has been replaced by the CT scan.

Venacavography is used for delineating the renal vein or caval tumor thrombus but has been replaced by MRI.

Percutaneous aspiration and biopsy is usually unnecessary. Biopsy is a reasonable method of diagnosis for patients with metastatic disease for tissue confirmation.

Solid renal tumor. The differential diagnosis for a solid renal tumor includes:

Renal cell carcinoma

Renal oncocytoma, which comprises approximately 3%–5% of solid renal tumors and has a benign natural history

Renal angiomyolipoma, which is a benign tumor that contains smooth muscle, blood vessels, and adipocytes. A CT scan can distinguish this tumor based on the presence of fat. This type of tumor is associated with tuberous sclerosis.

Fibroma, lipoma (rare)

Renal adenoma, which is thought historically to be benign. It is often found at autopsy and is less than 3 cm in size. Histologically, it is identical to renal cell carcinoma. It is now considered to be a small renal cell carcinoma.

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TABLE 25-4 TNM Staging Classification of Renal Cell Carcinoma

T (Primary tumor)

M (Distant metastases)

M0 No distant metastases

M1 Distant metastases present

Reprinted with permission from Lawrence PF, Bell RM, Dayton MT. Essentials of Surgical Specialties, 2nd ed. Baltimore: Williams & Wilkins; 1993:393.

Staging and prognosis

Staging classification (Table 25 -4)

Prognosis

Patients with lymph node metastases have a 5-year survival rate between 10% and 50%.

Patients with stage I lesions have a 5-year survival rate of approximately 75%.

Patients with stage II or IIIa lesions have a 5-year survival rate of approximately 50%.

Treatment

Stage I and stage II lesions

Radical nephrectomy (open or laparoscopic) is surgical removal of the ipsilateral adrenal gland, kidney, and investing adipose tissue and fascia. Regional lymphadenectomy may also performed.

Lymphadenectomy. For left -sided lesions, the para -aortic nodes are removed. For right -sided lesions, paracaval are removed.

Stages IlIa and IV. Treatment involves the concomitant excision of the renal vein or caval thrombus. The surgical approach is based on the extent of caval disease.

Stage IIIb

Minimal disease. Complete excision may be warranted, but the prognosis is poor.

Bulky disease or stage IV lesions may require nephrectomy for palliation of symptoms or for research and study purposes.

Metastatic renal cell carcinoma

Chemotherapy is essentially ineffective, possibly because of the frequent expression of the multidrug resistance (MDR) gene or P -glycoprotein.

Hormonal therapy is ineffective.

Immunotherapy. Ongoing investigations using interferon, interleukin, lymphokine-activated killer (LAK) cells, and tumor-infiltrating lymphocytes (TIL) have shown objective responses in 15%–30% of patients. Interferon plus nephrectomy has a median survival of less than 12

months.

E Testicular tumors

Pathology

The major germ cell tumors of the testis are seminomatous and nonseminomatous tumors. Nonseminomatous germ cell tumors (NSGCT) include embryonal carcinoma, teratoma,

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choriocarcinoma, and yolk sac tumors, alone or in combination. Secondary tumors include lymphomas.

Cryptorchidism (undescended testis) increases the risk of testicular malignancy.

Epidemiology

Although testis tumors are generally uncommon, they are the most common malignancy in men between the ages of 20 and 34 years.

Age. The tumor type is age dependent: Yolk sac tumors and teratomas are common in infants. All cell types may be seen in young adults: Seminoma is more common in men between the ages of 35 and 60 years, and lymphomas predominate in men older than 60 years.

Race. Testicular cancer occurs infrequently in blacks compared with whites.

Clinical presentation. Despite efforts to educate physicians and patients about routine testicular selfexamination, a significant delay is common before diagnosis. Approximately 33%–50% of patients have identifiable metastatic disease at initial presentation.

Local signs and symptoms

Painless swelling or enlargement of the testicle occurs in 65% of patients. Pain (13%–49%) suggests hemorrhage or infarction and may be confused with epididymitis.

“Heaviness” may be experienced on the affected side.

Failure of epididymitis to resolve as expected with appropriate antimicrobial agents should alert the physician to the possibility of occult malignancy.

Excessive pain or injury from minimal testicular trauma may indicate an underlying malignancy.

Signs and symptoms of metastatic disease prompt evaluation in 10% of patients and may include abdominal or back pain, nausea, anorexia, weight loss, gynecomastia, abdominal mass, cough, dyspnea, and hemoptysis.

Diagnosis

Physical examination may reveal a firm, nontender, or mildly tender distinct mass or diffuse testicular swelling.

A reactive hydrocele occurs in 5%–10% of cases.

Findings of gynecomastia or an abdominal mass suggest an advanced testicular malignancy.

Ultrasonography is very sensitive in determining the size, location, and echogenicity of palpable testicular abnormalities, particularly if a hydrocele limits the physical examination.

Serum marker levels of α- fetoprotein (AFP) and β-human chorionic gonadotropin (HCG) are useful for diagnosis, for following the response to treatment, and for identifying recurrent disease. AFP may be elevated in patients with yolk sac tumors, embryonal carcinoma, and teratocarcinoma. β-HCG elevation may accompany choriocarcinoma and seminomas. Seminomas do not elaborate AFP; thus, an elevation in this marker confirms a nonseminomatous component.

Definitive diagnosis requires surgical exploration via an inguinal approach to avoid potential “contamination” of scrotal lymphatic draining during tumor manipulation. Similarly, trans-scrotal biopsies should be avoided.

Staging is shown in Table 25 -5.

Metastatic evaluation should include a CT scan of the abdomen and pelvis and either a chest radiograph or a chest CT scan.

Postorchiectomy serum markers should normalize within predictable time periods based on their half - lives (AFP, T1-T2 = 5 days; β-HCG, T1-T2 = 1 day). Failure to normalize virtually confirms disseminated disease.

Treatment of testicular tumors varies with the cell type and stage of disease.

Seminoma is uniquely radiosensitive and chemosensitive.

Stage I seminoma. Postorchiectomy treatment options include close observation or radiotherapy (2,500 rad) to para -aortic with or without the ipsilateral pelvic nodes. Survival is approximately 100%.

Stage II seminomas

Receive retropetal radiation α

Stage IIb and c are best treated by systemic chemotherapy.

Survival approaches 95%.

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Reprinted with permission from Lawrence PF, Bell RM Dayton MT:

Essentials of Surgical Specialties, 2nd ed. Baltimore, Williams &

Wilkins, 1993:393.

Stage III. Current recommendations include up to four courses of chemotherapy with cisplatin, etoposide, and bleomycin. Postchemotherapy radiation is considered occasionally for patients with a residual retroperitoneal mass. An 85% complete response rate to chemotherapy and an overall survival rate of 92% can be expected.

NSGCT

Stage I NSGCT. Treatment involves inguinal orchiectomy followed by either modified retroperitoneal lymphadenectomy (RPLND) or by an intense surveillance protocol.

Surveillance is generally reserved for compliant patients who are at low risk of micrometastatic disease. Risk factors of the primary testis tumor favoring RPLND include an embryonal carcinoma component, vascular or lymphatic invasion, and extension into peritesticular structures.

RPLND involves surgical removal of specific high-risk lymphatic tissue. Approximately 30% of stage I patients have nodal disease at RPLND. Most patients with micrometastases receive two cycles of adjuvant platinum -based chemotherapy.

Survival for both groups approaches 100%.

Stage II NSGCT. Patients with minimal nodal involvement radiographically or failure to normalize markers postorchiectomy should undergo either RPLND or chemotherapy alone. Survival is approximately 98%.

Stage III NSGCT require induction chemotherapy employing platinum -based combinations for three to four cycles, with follow-up serum markers and radiographic re-evaluation. Markers and radiographs normalize in 70%–80% of patients, who can be followed without additional surgery. Those patients whose markers normalize but who have residual pulmonary, mediastinal, or retroperitoneal masses should undergo complete surgical resection of these masses. There is pathologic confirmation of carcinoma in approximately 20% of patients undergoing postchemotherapy surgery, and it dictates additional chemotherapy. Failure to normalize markers after chemotherapy portends a poor prognosis with or without additional surgery. Salvage chemotherapy or high-dose chemotherapy and autologous bone marrow transplantation may be considered in these cases.

Infertility issues in patients with testis cancer. Because testis cancer affects a population that is often interested in future fertility, counseling on this issue should be considered part of the treatment. Testis cancer itself adversely affects fertility, and the additional insults of surgical stress, orchiectomy, chemotherapy, and RPLND may further depress fertility. Men interested in future fertility should undergo preoperative semen analysis; if adequate parameters exist, sperm banking should be considered.

Taking the patient's history is very important when evaluating the cause of erectile dysfunction.

The nature of onset and the duration of the problem are important. Psychogenic impotence may be abrupt in onset with a life stress.

An interview with the patient's sexual partner may prove beneficial.

The presence of nocturnal or early morning erections may suggest a psychogenic cause.

History of pelvic trauma, including vascular or neurogenic injury, is important to discern.

Risk factors include diabetes, hypertension, smoking, heart disease, and hypercholesterolemia.

Physical examination. There is a special emphasis on the neurologic and vascular examination. A DRE is performed to evaluate for prostate cancer with general evaluation of the genitalia. The penis should be examined for plaques and the testes for size and consistency.

Laboratory tests include:

Testosterone level

Serologic tests for systemic disease (e.g., anemia, renal insufficiency)

Diagnostic tests are not indicated in every patient. They include:

Nocturnal penile tumescence. Measurements are taken of nocturnal erections occurring during rapid eye movement sleep. Gauges are placed on the flaccid penis at bedtime and attached to a monitor overnight that evaluates the number, duration, and rigidity of erections.

Intracorporeal injections of vasoactive substances , such as papaverine, phentolamine, and prostaglandin E, have been used to elicit an erection. Response with a normal erection eliminates a significant “venous leak” etiology for erectile dysfunction.

Duplex sonography evaluation can provide an objective measure of arterial penile blood flow as well as a relative assessment of venous drainage. Cavernosal arteries are evaluated for

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increased width and flow after intracorporeal vasoactive injection. Venous outflow during erections should diminish; if venous outflow is still high on duplex study, a venous leak phenomenon may be present.

Cavernosometry and cavernosography

Cavernosometry is a pressure flow evaluation of the penis during erection. After vasoactive injection, an erect penis requires little inflow infusion to maintain rigidity and high intracorporeal pressures. Cavernosometry evaluates the intracorporeal pressure and volume of necessary infusion to obtain and maintain an erection after a vasoactive injection.

Cavernosography is the injection of contrast material into the corpora to anatomically identify an abnormally excessive loss of venous blood during an erection.

Pudendal arteriography can identify isolated correctable lesions in a select population of postpelvic trauma patients.

The need for radiographic assessment in patients with urologic trauma is based on the mechanism of injury, vital signs, physical examination, and urinalysis.

Blunt trauma

Patients with gross hematuria or microhematuria and a systolic blood pressure (SBP) <90 mm Hg require radiographic evaluation of the kidneys.

Patients with microhematuria who have always had an SBP <90 mm Hg do not require a radiographic evaluation unless clinical suspicion is high based on the mechanism of injury (e.g., fall from a height, direct blows, high-speed motor vehicle crashes).

All patients with penetrating trauma , regardless of the degree of hematuria, require an evaluation.

Possible radiographic tests include an IVP, CT scan of the abdomen and pelvis, cystogram, retrograde urethrogram, and renal angiography.

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B Renal injuries

Classification: American Association for the Surgery of Trauma Organ Injury Scale

Contusion. There is no obvious parenchymal injury, but there may be a subcapsular hematoma.

Minor lacerations are superficial cortical disruptions that do not involve the collecting system.

Major lacerations are deep corticomedullary lacerations that do not involve the collecting system.

Deep lacerations of collecting system or injury to the renal artery or vein may be involved.

Avulsion of the renal vessels may occur, or the kidney may be shattered and destroyed.

Radiographic assessment includes:

CT scan of the abdomen and pelvis. It is the first -line test performed to rule out renal injury. Early venous phase and 10 -minute delayed images are required.

Renal arteriography is generally reserved for patients with possible vascular injuries that are not elucidated on the CT scan and may require embolization.

Treatment

Contusions, minor lacerations, and some major lacerations can be managed nonoperatively with bed rest, serial hematocrit evaluation , and hydration. Ureteral stenting may be required in cases of ongoing urinary extravasation.

Angiography and embolization can control most renal bleeding.

Major lacerations or vascular injuries usually require surgical staging and therapy.

Penetrating renal injuries usually require exploration, and in addition, they have a high risk of associated intra -abdominal injuries.

Surgical exploration includes debridement of nonviable renal tissue, closure of the collecting system, coverage of the injury with perinephric adipose tissue, and drainage of the retroperitoneum. Stents are usually not needed.

Repair of vascular injuries can frequently be problematic. Branch renal veins may be ligated, whereas arterial injuries with viable renal parenchyma require meticulous vascular repair. Prolonged ischemic time with arterial injuries usually mandates nephrectomy.

Complications of renal trauma

Post -traumatic hypertension appears to be uncommon but may occur in 5%–10% of patients and is mediated by renin owing to ischemic tissue.

Associated injuries are more common in patients with penetrating rather than blunt trauma. Right renal injuries are associated with liver trauma, and left renal injuries are associated with splenic injuries in blunt trauma. Bowel lacerations, pancreatic injury, and other vascular injuries occur with penetrating trauma. An initial identification of associated injuries with appropriate treatment will prevent many complications of renal trauma.

C Ureteral injuries

Etiology. Ureteral injuries are caused mainly by penetrating trauma or iatrogenic injury. Deceleration injuries may result in avulsion of the ureteropelvic junction, especially in children.

Radiographic assessment. The site of injury can usually be identified on IVP or CT. a. An intraoperative retrograde pyelogram can further delineate the injury.

Treatment. All ureteral injuries should be explored and repaired.

Upper and midureteral injuries are debrided, primarily repaired, drained, and stented.

Lower ureteral injuries usually require debridement, drainage, repair by ureteroneocystotomy, and stenting.

Iatrogenic crush injuries, if identified at the time of injury, can usually be managed by ureteral stenting alone.

Unrecognized injuries frequently present later as fistulas or urinomas, with fever and pain. Treatment of fistulas or obstruction may require stenting with or without percutaneous drainage. Primary open repair, after more than 3–5 days, risks renal loss.

D Bladder trauma (lower urinary tract)

Etiology. Blunt bladder trauma is frequently associated with pelvic fractures. Rupture can be extraperitoneal or intraperitoneal, depending on the location of the tear. Associated urethral injuries should always be considered as a possibility.

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Evaluation. Blood at the urethral meatus, an elevated prostate gland on DRE, or a mechanism of injury possibly causing a urethral tear should prompt a retrograde urethrogram before catheterization of the bladder. A 20–24 French urethral catheter should be passed into the bladder. Drainage and oblique films are necessary with plain film cystography. A cystogram involves maximally (400–500 mL) filling the bladder to determine extravasation of contrast medium (e.g., CT or plain film ).

Treatment. Many small extraperitoneal tears heal with a urethral catheter change alone. Extraperitoneal tears complicated by rectal or urethral trauma, any intraperitoneal tears, and exploration for other reasons require closure of the laceration and placement of a Foley catheter.

E Urethral injuries

Evaluation. The examination and radiographic assessment are described earlier (Chapter 21 C 7-D 1 a). A high index of suspicion should be maintained, because passage of a urethral catheter may significantly worsen a mild urethral injury.

Treatment

All penetrating anterior urethral injuries should be explored, debrided, and repaired primarily. A urethral catheter should be left in place after repair.

Complete prostatomembranous urethral disruptions from blunt trauma require open suprapubic tube placement.

Attempts at primary repair are not warranted.

Attempts at “realignment” over a urethral catheter or with flexible cystoscopes may be indicated.

Follow-up open repair of post-traumatic strictures should occur 3–6 months after the injury.

F Penile injuries

Fracture of the erect penis caused by direct blunt trauma that significantly bends the organ can result in a tear of the tunica albuginea of the corpora cavernosa. Urethral tears are associated injuries (20%).

Physical findings include ecchymosis, swelling, and deviation of the penis.

Diagnosis can usually be made based on the patient's history and physical examination.

Treatment involves operative repair via a circumcising incision and closure of any cavernosal tear. An evaluation via a urethrogram with repair of the urethral injury may be necessary.

Penetrating penile trauma is evaluated and treated similarly to a fractured penis. All such injuries should be explored and repaired.

G Testicular trauma

Blunt trauma. The physical examination is an integral part of the evaluation. Testicular rupture is the primary injury that requires surgical repair , and testicular ultrasound is frequently beneficial when making this diagnosis. A large hematocele is an additional indication for surgical exploration.

Penetrating trauma. The physical examination and ultrasound may prove helpful. All suspected testicular or spermatic cord injuries should be explored.