- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
Chapter 7 |
331 |
|
|
Miscellaneous urological diseases of the kidney
Cystic renal disease: simple cysts 332
Cystic renal disease: calyceal diverticulum 334
Cystic renal disease: medullary sponge kidney (MSK) 336 Acquired renal cystic disease (ARCD) 338
Autosomal dominant (adult) polycystic kidney disease (ADPKD) 340
Vesicoureteric reflux (VUR) in adults 342 Ureteropelvic junction (UPJ) obstruction in adults 346
Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation 348
Renal duplications 352
332 CHAPTER 7 Miscellaneous urological diseases of kidney
Cystic renal disease: simple cysts
Simple cysts are single or multiple renal masses ranging from a few to many centimeters in diameter that do not communicate with any part of the nephron or the renal pelvis. They are mainly confined to the renal cortex, are filled with clear fluid, and contain a membrane composed of a single layer of flattened cuboidal epithelium. They can be unilateral or bilateral and often affect the lower pole of the kidney.
In comparison, parapelvic cysts are simple parenchymal cysts located adjacent to the renal pelvis or hilum.
The prevalence of simple cysts increases with age. The precise prevalence depends on the method of diagnosis. On CT, 20% of adults have renal cysts by age 40 years and 30% by the age of 60. At postmortem, 50% of subjects aged >50 have simple cysts. Most reports show no gender predilection.
Cysts do not usually increase in size with age, but may increase in number.
Etiology
Both congenital and acquired causes have been suggested. Chronic dialysis is associated with the formation of new simple cysts.
Presentation
Simple cysts are most commonly diagnosed following a renal ultrasound or CT (less commonly after IVP) done for other purposes, and, as such, they represent an incidental finding. Very large cysts may present as an abdominal mass or cause dull flank or back pain.
The great majority of simple renal cysts are asymptomatic. Acute, severe flank pain may follow bleeding into a cyst (causing sudden distension of the wall).
Rupture (spontaneous or following renal trauma) is rare. Rupture into the pelvicalyceal system can produce hematuria.
Infected cysts (rare) present with flank pain and fever. Very occasionally, large cysts can cause obstruction and hydronephrosis.
Differential diagnosis
-Renal cell carcinoma
-Early autosomal dominant polycystic kidney disease (ADPKD)—diffuse, multiple, or bilateral cysts; presence of hepatic cysts
-Complex renal cysts (i.e., those which contain blood, pus, or calcification)
Investigation
Renal ultrasound
Simple cysts are round or spherical, have a smooth and distinct outline, and are anechoic (no echoes within the cyst—i.e., sound waves are transmitted through the cyst). Evidence of calcification, septation, irregular margins, or clusters of cysts requires further investigation (CT 9 aspiration, MRI). In the absence of these features no further investigation is required.
CYSTIC RENAL DISEASE: SIMPLE CYSTS 333
CT (see Table 7.1)
Simple cysts are seen as round, smooth-walled lesions with homogenous fluid in the cavity (with a typical density of –10 to +20 Hounsfield units), and with no enhancement after contrast (enhancement implies that the mass contains vascular tissue or communicates with the collecting system, i.e., that it is not a simple cyst).
Hyperdense cysts have a density of 20–90 Hounsfield units, do not enhance with contrast media, and are <3 cm in diameter.
Treatment
A simple cyst (round or spherical, smooth wall, distinct outline, and no internal echoes) requires no further investigation, no treatment, and no follow-up. In the rare situation where the cyst is thought to be the cause of symptoms (e.g., back or flank pain), treatment options include percutaneous aspiration ± injection of sclerosing agent or surgical excision of the cyst wall. In the rare event of cyst infection, percutaneous drainage and antibiotics are indicated.
Cysts with features on ultrasound suggesting possible malignancy (calcification, septation, irregular margins) should be investigated by CT with contrast.
Table 7.1 Bosniak classification of CT appearance of simple and complex cysts
Type |
Description |
Approx. % of |
Treatment |
|
|
such cysts that |
|
|
|
are malignant* |
|
|
|
|
|
I |
Simple benign cyst with |
None |
None; no follow-up |
|
no smooth margins, no |
|
required |
|
contrast enhancement, |
|
|
|
no septation, no |
|
|
|
calcification |
|
|
II |
Smooth margins; thin |
10% |
Observation—repeat |
|
septae; minimal |
|
ultrasound looking for |
|
calcification; no |
|
increase in size or |
|
contrast enhancement |
|
development of |
|
Includes high-density |
|
malignant features |
|
(hyperdense) cysts |
|
|
III |
Irregular margins; |
40–50% |
Surgical exploration 9 |
|
moderate calcification; |
|
partial nephrectomy |
|
thick septation (septae |
|
|
|
>1mm thick) |
|
|
IV |
Cystic malignant lesion; |
90% |
Radical nephrectomy |
|
irregular margins and/ |
|
|
|
or solid enhancing |
|
|
|
elements |
|
|
|
|
|
|
* From Siegel et al. (1997). Study relating CTs of cysts where pathological identification had been performed. AJR Am J Roentgenol 169:813–818.
334 CHAPTER 7 Miscellaneous urological diseases of kidney
Cystic renal disease: calyceal diverticulum
A calyceal diverticulum is an outpocketing from the pelvicalyceal system, with which it communicates by way of a narrow neck. It is lined by a smooth layer of transitional epithelium and is covered by a thin layer of renal cortex.
The etiology of calyceal diverticula is unknown. They are usually asymptomatic and are discovered incidentally on an IVP. Symptoms may result from the development of a stone or infection within the diverticulum, presumably caused by urinary stasis.
Stones that form within the calyceal diverticulum may be treated by flexible ureteroscopy and laser lithotripsy or, if large, by percutaneous nephrolithotomy (PCNL) (if percutaneous access is possible). Extracorporeal shock wave lithotripsy (ESWL) may result in stone fragmentation, but it may be difficult for the stone fragments to get out of the diverticulum and they may simply reform into a larger stone.
Endoscopic dilatation or incision of the neck of the diverticulum may be attempted at the time of stone surgery to prevent recurrence, and this technique can also be employed if the diverticulum is thought to be the cause of recurrent urinary infection.
Open surgery has been used to remove stones and to de-roof calyceal diverticula.
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