Jian F. Ma, MD, PhD Chief of Urology and Ambulatory Surgery Group Health Bellevue Medical Center ©Jian F Ma Genitourinary Organs  Adrenal gland  Kidney  Ureter  Bladder  Prostate  Urethra  Penis  Testis/Scrotum Adrenal Cortex Diseases  Excessive Glucocorticoids  Cushing    Pituitary: ACTH Adrenal Cortex Hypertrophy Iatrogenic  Tests   Dexamethasone suppression test Saliva cortisol test, equally effective, approved by FDA Adrenal Cortex Diseases  Insufficiency (Addison’s Disease)  Chronic  Acute: life threatening!!!   Adrenal hemorrhage in pregnancy Stress dose of steroid during surgery or trauma Adrenal Medulla Diseases  Pheochromocytoma  Episodic hypertension, arrhythmia  Can be familial (25%): MEN 1, MEN 2 etc  Diagnosis: Plasma metanephrine (most accurate)  Imaging: MIBG Adrenal Medulla Diseases  Treatment  Phenoxybenzamine  Surgery:    Laparoscopic or open adrenalectomy Very high intraoperative risk of vascular collapse Only done in specialized centers Adrenal Malignancy  Rare: 1-2 per million  Can be hormonally active  Early metastasis  Treatment  Surgery  Radiation (palliative)  Chemotherapy: mitotane (metastatic)  Derivative of DDT  Prognosis: Poor, 25% five-year survival Benign Renal Pathophysiology (Urology)  Obstruction (hydronephrosis)  Infection/inflammation  Nephrolithiasis Renal Obstruction: Definition Whitaker Test 10 mm H2O is physiologic 23 mm H2O or above is obstructive Renal Obstruction  Ureteral  Congenital  Stone  Cancer  Stricture (post surgical, trauma, radiation) Renal Obstruction: How to unobstruct  Stent  Nephrostomy Renal Obstruction  Ureteropelvic Junction  Mostly congenital  Dietl’s Crisis  Management   Stent, nephrostomy Laparoscopic (open) Pyeloplasty Renal Obstruction: Treatment Treatment of stone/tumor Incision: laser, electrical, knife Dilation Excisional Repair Ureteroureterotomy Distal reimplantation Auto transplantation Nephrectomy: Function less than 15-20% Symptomatic Renal Infection  Pyelonephritis  Cx: usually more ill than cystitis, may progress to urosepsis (may deteriorate explosively to ARDS in hours)  Urine and blood culture  Rule out obstruction: immediate drainage  Ultrasound, CT, MRI, Diuretic Renogram, Retrograde Pyelogram  IV broad spectrum antibiotic, then switch to culture appropriate po antibiotic, total of 2 weeks therapy Renal Infection  Obstructive Pyelonephritis  From obstructive stone or stricture/injury  Medical therapy usually not sufficient until the obstruction is treated (stent, nephrostomy)  If workup is delayed, may progress to urosepsis  Poor outcome, medicolegal risk Nephrolithiasis  Common illness:  15% prevalence  $3 billion in 2003 in US  Indirect cost far more than $3B  Hippocratic Oath  Do no harm  “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work” Nephrolithiasis: symptoms  Nephrolithiasis usually is asymptomatic  Renal colic from obstruction when the stone migrates to ureter  The level of pain  Nausea and vomiting  From hollow viscus obstruction  Obstructive pyelonephritis  Fever and chills  Hypotension Nephrolithiasis: Size and Location  Average caliber of the ureter 5-6 mm  2 mm 80% chance of spontaneous passage  5-6 mm 50%  8 mm 20%  Locations  UPJ  Iliac crossing  UVJ Nephrolithiasis: Indications for Intervention  Management of Obstruction: stent, NT  Obstructive pyelonephritis: fever, chills etc  Dehydration from vomiting  Poorly controlled pain  Surgical Intervention: lithotripsy  Failure to progress  Unable to tolerate stent, nephrostomy tube  Large size, proximal location  Special circumstances  Commercial pilots, captains, fire/policemen, drivers etc Nephrolithiasis  Stone composition  Majority: calcium oxalate (monohydrate and dihydrate)  Mostly dietary and hydration related  Calcium phosphate  Metabolic acidosis  Uric acid   Dietary, gout, “disease of the kings” Alkalinization: baking soda, potassium citrate  Struvite (magnesium ammonium phosphate)  UTI related (urea splitting organism) Nephrolithiasis: Risk Factors  Family history  Profession  Limited fluid intake  Weather  Dehydration  Medical conditions  IBD, Crohns, UC  Gastric bypass, short gut  Parathyroid  Sarcoid etc Nephrolithiasis: Dietary Factors  The single most important contribution  Sodium, protein, fat “rich food”  Pediatric stones  From “rare” to “common” in the last several decades  Strong correlation with obesity, cardiovascular disease and diabetes Nephrolithiasis: Prevention  Dietary/behavioral change  Hydration (3 liters per day)  Low sodium, low protein food  DASH (dietary approach to stop hypertension) Diet  Lemon juice: citric acid Kidney Cancer (parenchymal)  Type  Clear cell (most common), papillary, chromophobe etc  Stage  Can form tumor thrombus and extend through vena cava all the way to the right atrium  Metastasis: nodal, lung, bony, hepatic Kidney Cancer (parenchymal)  Treatment  Surgery: only curative therapy  Chemo: not effective  Immunotherapy and radiation only palliative  Surgery  Total nephrectomy (laparoscopy, open)  Nephron sparing (partial nephrectomy)  Minimally invasive therapy: unproven durable result  For patients with inability to tolerate radical surgery or limited life expectancy Kidney Cancer (urothelial)  Transitional (same as bladder cancer)  5% of the bladder cancer patients may develop upper tract transitional cell carcinoma  Treatment  Endoscopic for small, solitary lesion  Nephro-ureterectomy for large, multifocal, invasive tumor Benign Renal Tumor  Cyst: Defined by complexity, not by size  Bosniak 1-2: no follow-up  Bosniak 2F: follow up  Bosniak 3-4: surgery  Angiomyolipoma  May cause spontaneous bleeding (in pregnancy)  Surgery for over 4 cm (angio-ablation, partial nephrectomy)  Oncocytoma  Solid tumor  Diagnosed after nephrectomy Bladder  Storage of urine  Normal adult: about 500 ml (about 5 hours of urine)  Can be as big as 1 liter (under anesthesia)  Detrusor (smooth muscle)  Passive during storage  Active during micturition  Post void residue (PVR)  Should be zero in a young man Bladder  Failure of storage  Urgency, urge incontinence   Idiopathic (overactive bladder) Neurogenic: CNS  MS, post stroke, spinal cord  Failure of emptying  Retention, atonic bladder Anatomic: prostatic or urethral obstruction Neurogenic: CNS/PNS MS, spinal cord injury, pelvic surgery/injury Bladder: Failure of storage  Rule out neurogenic problem  Most common back problem  Medical treatment: anticholinergic  Major side effects: dryness, constipation, poor compliance  Contraindication: close angle glaucoma  Surgical treatment  Botox: needs reinjection every 9-15 months, just like the face  Interstim (sacral pacemaker) Bladder: Failure of emptying  Catheterization  Indwelling vs self catheterization Benjamin Franklin developed a flexible urinary catheter that appears to have been the first one produced in America. But his relationship with his patient (his brother James) was not as friendly, and Ben was forced to escape his abusive brother to go to Philadelphia. Bladder: Failure of emptying  If possible, intermittent catheterization is preferred  Less infection (no foreign body long term)  More patient comfort (no constant penile irritation)  The patient may still void in between  Suprapubic catheterization  No penile irritation  UTI risk same as penile catheterization  Requires minor anesthesia, small risk of bowel injury Bladder: Failure of emptying  α-blocker  Prazosin (Minipress), terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatrol), silodosin (Rapaflo)  Side effects  Orthostatic hypotension  Retrograde ejaculation  Floppy iris syndrome (during cataract surgery) Bladder: Failure of Emptying  Surgery: to open the obstruction  Stricture (endoscopic, open repair)  Enlarged prostate  Prostate surgery  Prostatic incision  Minimally invasive therapy: microwave, etc  Laser procedure (greenlight)   New but not necessary gold standard, outpatient surgery Re-operation rate 28%  Transurethral Resection of the Prostate (TURP)  Gold standard: re-operation rate 3-5 % per year Bladder: UTI  Risks  Fecal-vaginal colonization  Urinary stasis (from bph, stricture, neurogenic bladder)  Foreign body (stone, catheter)  Treatment: only bph, stricture and stone can be treated surgically, the rest medically Bladder: UTI  Urine culture (not urine analysis)  Asymptomatic bacteriuria DOES NOT require treatment  Please don’t culture old ladies in SNF without symptoms  Culture sensitive antibiotic  Prophylaxis: very low dose of antibiotic  Natural prophylaxis  Cranberry  Probiotic: fecal-vaginal colonization with friendly bacteria Bladder Cancer  50,000 new cases per year  Risk factors  Smoking (tobacco, marijuana), chemical exposure, prior radiation, chemo (cyclophosphamide)  ?Actos  Field defect: the entire urothelial surface at risk  At diagnosis  85% localized, 38% muscle invasive  15% metastatic Bladder Cancer: Superficial Cancer  Ta (subepithelial): resection  T1 (lamina propria)  Resection, intravesical chemotherapy (mitomycin)  Adjuvant immunotherapy (BCG, mitomycin etc)  CIS: unpredictable behavior, disease progression  BCG, BCG plus interferon  Cystectomy uncommon (4,000 vs 50,000 new cases)  For multifocal, recurrent, persistent disease  Recurrent, persistent CIS  Non-compliance Bladder Cancer: Invasive  T2, T3: radical cystectomy  T3-4: palliative cystectomy (for bleeding, urinary diversion, local symptoms etc)  Urethrectomy Hematuria Workup  Gross hematuria (flank hematuria)  Microscopic hematuria  Old def: 3 RBC/hpf in 2/3 UA  New def: 3 RBC/hpf in ONE UA (no dip)  Patients on anticoagulant: still need workup  Upper tract study  Multiphase CT, MR  Ultrasound less optimal, no body radiation  Lower tract study  Cystoscopy Prostate: BPH  BPH  Anatomic definition  Happens to EVERY MAN if he lives long enough  No treatment unless symptomatic (LUTs, or lower urinary tract symptoms) Prostate Cancer  Epidemiology  About 300,000 new cases, 30,000 deaths  breast cancer 39,000 deaths  Late patients very symptomatic    Bone pain, kidney and bladder obstruction It takes a long time to die (5-8 years not uncommon) Very debilitating, and costly Prostate Cancer  Screening  How to diagnose the lethal kind of cancer   Before 1985, DRE alone, mostly advanced stage cancer PSA era, mostly early cancer, mortality decreases by 40%  Also over-treatment, side effects  Other markers not widely adopted (PCA3 etc)  Controversial  USPTF: grade D (do not recommend)  So far very few organizations choose to follow  Obama got his PSA three times (age 46, 48, 50), most recently Sept 2011, after USPTF recommendation  Canada does not pay for screening PSA (but pays for prostate cancer treatment) Prostate Cancer  Screening consensus for now  Life expectancy 10 years or more   40-75 Reasonably good health  High risk population   African American Family history  PSA and DRE  Things may change after 2014  Canadian model? Prostate Cancer  Diagnosis  Prostate biopsy  Transrectal, transperineal  Well tolerated  3-5% of urosepsis (bacterial prostatitis), usually because of resistant bacteria  10-12 cores  Additional studies   CT for pelvic adenopathy Bone scan: only useful in PSA over 20 Prostate Cancer  Prognosis  Biopsy finding  Higher Gleason Scores (4 or 5)  Nomogram  D’Amico Prostate Cancer: Treatment  Watchful waiting  For low and intermediate risk groups  Serial PSA, periodic bx to monitor disease progression   No treatment side effects Unpredictable disease progression  Expect more in the future   The right thing to do? Cost? Prostate Cancer: Treatment  Surgery  Open surgery   Radical retropubic prostatectomy Perineal prostatectomy  Laparoscopic w/wo robotic assistance  Overall no difference  Side effects: SUI, impotence Prostate Cancer: Treatment  Radiation  External Beam Radiation (including proton beam), brachytherapy (seeds)  No difference  Side effects    Still has a prostate (obstruction, bleeding etc) Rectal, bladder, urethral injury Secondary pelvic malignancy (8% life time risk)  Bladder, rectum Prostate Cancer: Treatment  Cryotherapy  HIFU (high intensity focal ultrasound, not approved in US)  Like brachytherapy  May have significant local side effects Prostate Cancer: Treatment of Metastasis  Hormone deprivation therapy  Castration controls the growth of prostate cancer graft   Nobel Prize 1966 (Huggins) Surgical castration, chemical castration Nobel Prize 1977 Guillemin, Schally Prostate Cancer: Metastasis  Hormone deprivation therapy  Castration, LHRH agonist, antagonist  Antiandrogens  Adrenolytic agents, steroid  Immunotherapy  Chemotherapy  Palliative radiation for bone pain  Other supportive measurements  Nephrostomy, suprapubic tube  Channel TURP Urethra  Stricture Urethral Stricture  Causes  Injury (trauma, instrumentation, radiation/laser/cryo)  Inflammatory (STD)  Symptoms  Similar to Luts in elderly men  Younger age, history  Treatment  Endoscopic incision, dilation  Open repair, primary vs buccal mucosa graft Hypospadias  Urethral opening not at the tip  Neonatal exam  Not life threatening, elective referral  UNLESS NO GONADs   Congenital adrenal hyperplasia Salt wasting form, life threatening  Urinary stream, infertility (proximal)  Repair  Usually after 6 months (safer anesthesia) Phimosis  Physiologic  Circumcision  79% in 1980, 55% in 2010  Washington State: 25%  Neonatal circ at bedside, after 1-2 week with anesthesia  Pros: uti (in young children), balanitis, viral infection transmission (hiv, herpes, hpv, including risk in women)  Penile cancer   0% in Israel (near 100% cir), 0.2/100,000 in US (80% circ) Highest in India 3.3/100,000 and Brazil 6.8/100,000 Phimosis: Debate  AAP: Health benefits of circumcision outweigh the risks (2012)  Declining circumcision rates may add $4 billion in U.S. health care costs (CBS News, 2012)  A German court decides that ritual circumcision amounts to criminal bodily harm, fear of national ban  San Francisco Male Genital Mutilation Ballot  “Inactivitist Movement” Erectile Dysfunction  Mechanism of erection  Vascular  Parasympathetic nervous system  Mechanism of ED  Arterial insufficiency: atherosclorosis  Venous insufficiency: venous leak  Nerve damage   Peripheral neuropathy: DM, pelvic surgery/radiation, etc Central: spinal cord injury Erectile Dysfunction: Treatment  Medical Therapy  PDE5 inhibitor (Viagra, Levitra, Cialis)   Increase arterial flow Contraindications: nitro, retina  Prostaglandins   Penile injection Transurethral suppository  Vacuum device Erectile Dysfunction: Treatment  Surgical Therapy  Pros   Highly effective Satisfaction rate 90% +  Cons    Surgery-anesthesia Complication  Infection  Malfunction Cost $20,000+, self pay Penile Cancer  Etiology  HPV  Uncircumcised state  Treatment  Small, superficial lesion  Local treatment  Large, deep, higher grade cancer   Partial vs total penectomy (with perineal urethrotomy) Lymph node dissection  Chemotherapy, radiation therapy palliative Testis: Cryptorchidism  Function  Spermatogenesis (requires a lower temp 35 ˚C)  Hormone  Cryptorchidism  40% premie, 3% term, 1% at 1 yo  Observation  Surgery at 1 year  Bilateral cryptorchidism AND Hypospadias: rule out salt wasting intersex Testis: Torsion  Ischemia due to volvulus of the cord  Usually in young men  Sudden onset of pain  Can have intermittent torsion  Testis can survive for 6 hours  Not salvageable after 24 hours  Diagnosis    Physical exam Doppler ultrasound If clinically suspicious, scrotal exploration  Testis: Benign Scrotal Mass  Hydrocele and Spermatocele  Only symptomatic masses require Rx  Hydrocelectomy: 15% recurrence  Aspiration: 100% recurrence  Varicocele  Common in young men: 15% of army recruits  Indications for therapy (varicocelectomy or embolization)   Pain, arrested testis growth, infertility Testis: Infertility  Definition  Unable to conceive after one year of unprotected sex  15% of couples infertile,  30% male factor, 40% female., 30% both  With modern technology, almost all couples can “reproduce”  Male factors  Post vas  Varicocele  Other factors: mumps, smoking, prior chemo-radiation Testis: Vasectomy  Procedure  Most done as an outpatient procedure  Cost: between “free” to $4,000  Short recovery, no permanent deficit (including sexual), no future cancer  Semen test: azoospermic (only 30% back for test)  Complications  Hematoma, infection  Post Vas Pain Syndrome (PVPS)   Can happen years later From epididymal congestion Testis: Vasectomy Reversal  Procedure  8% are reversed  Effective 70%  Almost no insurance coverage (except Microsoft, Amazon, Starbucks)  Cost: $10,000 to $20,000  Occasionally done for PVPS Testosterone Supplement  ADAM: Androgen Deficiency in Aging Males  Symptoms   Low energy, libido, physical abilities Low or low-normal serum testosterone level  Unlike "menopause", the word "andropause" is not currently recognized by the World Health Organization and its ICD-10 medical classification Testosterone Supplement Testosterone Supplement: FDA  Testosterone is indicated for replacement therapy in the male in conditions associated with symptoms of deficiency or absence of endogenous Testosterone    Primary hypogonadism (congenital or acquired)-testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome; or orchidectomy. Hypogonadotropic hypogonadism (congenital or acquired)-idiopathic gonadotropin or LHRH deficiency, or pituitary-hypothalamic injury from tumors, trauma, or radiation. Testosterone Supplement: FDA  Contraindications  Known hypersensitivity to the drug  Males with carcinoma of the breast  Males with known or suspected carcinoma of the prostate gland  Women who are or who may become pregnant  Patients with serious cardiac, hepatic or renal disease Testis: Cancer  Presentation  Young men, 8,000 per year in US  Painless mass  Ultrasound  Seminoma most common  Nonseminomatous germ cell tumor NSGCT more dangerous  Staging workup   Serum markers: β-hcg, AFP, LDH CT of the chest and retroperitoneum Testis Cancer Scrotum and Perineum: Fournier’s Gangrene  Necrotizing infection  Named after Jean Fournier, first described in 1764  5 previously healthy young men suffered from a rapidly progressive gangrene of the penis and scrotum without apparent cause.  Can happen at any age, more in immune-compromised population (DM, steroid, morbid obesity etc)  Mortality rate near 50% Fournier’s Gangrene  Presentation  Both aerobic and anaerobic bacteria  Blistery, bubbly/rice crispy (gas gangrene), not necessarily purulent  Rapidly progressing erythema line (up to one inch per hour)  Treatment: Surgical debridement, abx, supportive