Uro

Question 1

Urology summary

Question 2

Done by: Haya Yanes, Printed & modified by: Amal Awwad, Leen Al-Saheli, samia simrin Fatima messad

Question 3

Renaltumors:

Question 4

• Pelvi-calyceal System
Cloacal Membrane
* Transitional Cell Carcinoma
* Nephroureterectomy & bladder cuff

Question 5

• Parenchymal Mass
Metanephric Blastema (embryology) Adenocarcinoma / RCC (M.C. Tumor) Radical Nephrectomy (M.C. Surgery)

Question 6

• After knowing the origin of the mass you have to determine whether it’s Benign
  /Malignant… there’s NO specific investigation that Can tell you.. so you have to consider it Malignant Until Proven otherwise.
  Note that Parenchymal Masses : 1- Benign
  a. Adenoma: very small <3cm, Asymptomatic, Originates from PCT
  b. Angiomyolipoma: hamartomas that appear in child bearing female, associated withTuberousSclerosis.
• Found incidentally on U/S or CT, but in 10% of cases may Present with Massive retroperitoneal bleeding leading to patient collapse
• Only beign mass can be distinguished On CT scan ( Fat Containing Tissue).
  -It’s Very vascular so embolization of feeding Artery Can be the treatment. If tumor < 4 cm & Asymptomatic.  Observe
  But If > 4 cm  excise

Question 7

c- Oncocytoma: Originates from collecting ducts. (uncommon), M>F, Incidental. Treatment: Partial Nephrectomy (Indications): Bilateral tumor (VHD), Single kidney, Renal Impairment (DM) Lesion (<4 am

Question 8

• Masses can be Solid or Cystic (MC), screen Initially with US, confirm with Contrasted CT scan.
  For cystic masses, we have Bosniak Classification:
  1) 0% are malignant.
  2) 0% are malignant (Cyst with minimal Separation)
  2F (need follow up → More septation. Increase suspension for Malignancy.
  3) 50% are malignant
  4) 100% are malignant

Question 9

No enhancement of contrast, No hyper vascularity

Question 10

• RF for renal tumors: HTN, obesity, smoking, Family Hx, Asbestos, renal dialysis, horseshoes & PCK, VHL genes (ch 3,7,17), Phenacetin Drug (Analgesia).
• Presentation: Asymptomatic (70%), Paraneoplastic Syndrome (ectopic horm),
  Classical Triad: Painless hematuria, Mass, Flank Pain.
• Investigations: u/s, Contrasted CT (gold standard).
  Needle Biopsy is contraindicated (fear of seeding & hemorrhage).
  Tumor Spread:
• Direct extension: adrenal gland, renal vein & IVC & Sometimes to R Atrium.
• LN; hilar & Para-aortic LN.
• Hematogenously; Lung, liver, bone, brain.

Question 11

Malignant: RCC / Adenocarcinoma: M.C. renal Tumor, M>F age 60-80.
-grading  grade 1: well differentian.
 grade 2: moderate.
 grade 3: Poor differentiation.
- Staging /T staging
Stage 1 (confined to kidney <7 cm) Stage 2 (confined to kidney >7 cm). Stage 3 extension to: T3a: Adrenals
T3b: renal vein or to IVC T3c: Above diaphragm.
Stage 4 (Invading gerata’s fascia & other organs)

Question 12

ProstateCA
* prostate anatomy: prostate is located under the neck of the bladder, it Produces 25% of seminal fluid, It’s made of glandular epithelial & Stromal tissue. It’s growth maintained by hormones mainly (DHT).
- Tumor arises from Peripheral Zone (Asymptomatic In 70% of caes).
• Function: Secretion of PSA: glycoprotein that liquefy the semen & ↑ fertilization.
RF: Age, Black M, FHx (x2 risk in 1st relative <55y), High fatty diet (Western), Sexual Over-activity, Vasectomy PTEN & P53 Inactivation & c-myc Activation.
 Vit. D, E, Lycopene (Anti-oxidant) & Selenium ↓ PC growth
Presentation  Asymptomatic, hematuria, LUTS, Perianal discomfort, renal failure, AKI , If Mets: SOB, weight, Anorexia, Bone Pain, LL edema
Diagnosis: NO Screening Test, Most definitive Dx is histopathology. .
1. PSA: high suspicion for CA If…
-velocity > 0.75 -Density > 0.15, -Ratio < 20%. -Total >10
2. DRE: Look for consistency, size, nodularity, Symmetry.
- Normal Prostate weight is 20 g, 3-4 cm long. It’s bi-lobed with median Salcus
- Don’t Do DRE If there’s Prostatitis, or Prostate Abscess
3. TRUS:
↳ Without Biopsy Azospermia, suspected Prostate Abscess, To Assess the volume, chronic Pelvic Pain.
↳ With Biopsy, Abnormal DRE / ↑ PSA, Abnormal Previous Biopsy To Confirm viable PC following Treatment.
Complications: UTI, Vasovagal Syncope, hematuria / hemato-spermia / Rectal Bleeding, Uro-sepsis or Sepsis in general (fatal).
* Grading: Gleason score (2-10)
We take 12 samples then Put grade 1-5 for most dominant differentiation of Cells to least one then combine these 2 numbers:
- 2-6 well differentiated.
- 7 moderate.
- 8-10 Poorly differentiated.

Question 14

• Staging by DRE (size, T stage), CT &MRI (N&M stage)
  T Stage
  T0 N0 tumor Tx uncertain
  T1 Impalpable Tumor on DRE
  T1a: 5% or less PC tissue found after TURP/Incidentally T1b: More than 5% PC tissue Round after TURP
  T1c: Tumor Round by needle biopsy → made due to ↑PSA
  T2 & T3 Palpable on DRE

Question 15

Treatment:
A) radical Prostatectomy: confined to Prostate (T1-T2) No N or M Involvement.
when PSA ≤20, moderate differentiation (Life expectancy >10, (T1-T2))
Complications: Urinary Incontinence, Impotence, erectile dysfunction, reduce Penis length, Lymphedema, bladder neck stenosis, obturator N Injury.
B) Waiting & Observe: 89 yr old Pt, ↑ PSA; gleason 10, low life expectancy <10 yrs
C) Active Surveillance (DRE/6 months & Biopsy every year): waiting for Progression, Pt with LUTS, with BPH, then biopsy comes to be malignant.
D) Hormonal, GnRH agonist with radio: If Mets give continuous dose of GnRH.
*Open Prostatectomy is contraindicated.
* PC is Almost Always Adenocarcinoma (glandular tissue)
* PC extend to Iliac LN

Question 16

BladderCA:
Specific gravity 1.005-1.025 + osmolality 300-1,090 MOSM/Kg
* It’s 2nd M.C urological Malignancy, M.C in white males around the age of 80.
* RF: Smoking (most important), drugs like phenacetin & Cyclophosphamide.
Tumor spread: Direct extension: detrusor muscle, urethral orifices; prostate.
:Lymphatic infiltration Iliac & Para-aortic LN
: Hematogenous spread: Lung, liver, bone, Adrenals.
:Implantation Into wounds / Percutaneous Catheter…
Histological grading (differentiation):
G1 (well differentiated), G2 (Moderately), G3 (Poorly, high grade).
Staging (T stage)
-Tis / CTS (Not invading Basement mem.)
-Ta noninvasive Papillary Carcinoma
-T1 subepithelial Connective tissue
-T2 Invasion to muscularis propria, Detrusor
-T3 Invasion to perivesical fat
-T4 invasion to other organs

Question 17

Presentation:
Hx: Painless Macroscopic total hematuria, LUTS, recurrent UTI & Pneumaturia (Colovesical Fistula) LL swelling (lymph. /veinous Obstruction).
PE: Suprapubic Mass (T4), Bimanual exam in ♀ &, DRE (mass above or Involving Prostate), Pallor (due to anemia).
Investigations: CT urography, Urine Cytology +ve in CIS specific, TURBT (Dx &Tx).
**If Biopsy-Proven Muscle-Invasive Bladder CA → Staging Investigation (CT, MRI,
bone scan)
Types:
1) TCC urothelial Carcinoma (90%): Single or multifocal - Superficial or muscle- Invasive, M.C. in the Floor (>Carcinogen exposure)
a. Papillary (GI / G₂) 2 Ta(Mucosa / Superficial) T1 (Sub mucosa)
b. Solid/Mixed (G3) 50% are Muscle-Invasive.
c. CIS/G3 (Poorly Differ.): Confined to epithelium, aggressive 100% + urine cytology.

Question 18

2) SCC: Solid, ulcerative (Muscle-Invasive ), Associated with Smoking, schistsoma
- Can be due to: Bladder stones, Catheters
- bilharzial has better prognosis than non-bilharzial.