a tient's
- influ-
ion
ronary
Urological surgery
Assessment 399
Upper urinary tract (kidney and ureter) 402
Lower urinary tract (bladder, prostate and urethra) 406
General points
Patients may present with symptoms clearly related to the
urinary tract but seemingly unrelated symptoms rnay be
urological; backache from metastatic prostatic carcinoma,
fever of unknown origin from renal carcinoma, lethargy
and anaemia from obstructive renal failure.
Urinary tract symptoms
Pain
Afferent innervation of the urinary tract is rudimentary and as
such pain originating from these organs, though characteristic,
may not easily be localized. Renal pain occurs in the angle
between the 12th rib and the sacrospinalis muscles. Ureteric
pain (or colic) typically radiates forwards and downwards
towards the groin, testes or labia, following the dermatomes
relating to the nerve roots from which the sympathetic inner-
vation of the ureter originates (i.e. T10-L2). Acute bladder
obstruction usually causes central lower abdominal pain. By
contrast, chronic bladder obstruction may be virtually asymp-
tomatic. Disease of the bladder and prostate causes iil-defined
perineal or penile pains. A prostate that is grossly enlarged
can cause rectal symptoms, including tenesmus.
Disorders of micturition
The history aims to distinguish between obstruction (e.g.
poor stream), storage problems (e.9. urgency), infection (e.g.
frequency, dysuria) and malignancy (e.9. dark, discolored
or brown urine). Frequency is recorded numerically: D/N
6/3 (by day, six times; by night, three). Hesitancy, poor
stream and dribbling are characteristic of urinary outflor,r,
tract obstruction. Urgency, a sudden uncontrollable desire
to void, may be associated with incontinence (urge incon-
tinence). Stress incontinence relates to the involuntan' loss
of urine due to coughing, sneezing or straining. Dvsuria
describes painful micturition.
Disorders of micturition - incontinence 417
External genitalia 419
Examination
Examination should not be confined to the urinary system,
as cardiological, neurological and gynaecological problems
may be associated with urological symptoms and signs.
Many urological patients are elderly and require an
assessment of their fitness for further investigations and
operative treatment. Furthermore, the patient's cardiov-
ascular status may be relevant to subsequent treatment: for
example, administration of oestrogens for carcinoma of the
prostate.
With the patient relaxed, the kidney can be balloted; lifted
with one hand placed behind the loin and compressed by
the other hand pressing downwards (Fig. 23.1). The ureter
cannot be palpated. An enlarged bladder rises centrally out
of the pelvis, is dull to percussion and may even be visible.
In men, the hernial orifices, cords, testes and epididy-
mes are examined with the patient standing and lying. If
the foreskin is uncircumcised, it must be confirmed that
it retracts and that the glans and meatus are normal. In
women, the vulva, urethra and vagina must also be exam-
ined. A speculum examination should be carried out if
there is any suspicion of vaginal or cervical abnormality.
A full pelvic bimanual examination, whether in males or
females, is best carried out under general anaesthesia with
a muscle relaxant. A rectal examination is mandatory, not
only to examine the prostate but also to detect abnormali-
ties of the anal margin (haemorrhoids, fissures) and iower
rectum (carcinoma).
lnvestigations
Urine
In the absence of infection, urine is normally almost pro-
tein-free. Proteinuria of more than 150mg/24 hrs mandates
further investigation. Glycosuria suggests the presence of
diabetes. Screening for urinary tract infection may also be
done bv Dipstix. Microscopic examination may detect casts
or tubular epithelial cells associated with renal parenchymal 399
T
,.8
i:
1

I
,:

!l

Fig.23.1 Bimanual palpation ofthe right kidney.

disease, crystals in patients with renal calculi, or ova in

schistosomiasis. Cytology and, more recently, urinary cel-
lular markers are useful in the diagnosis and follow-up of
bladder (and other urothelial) cancers. For rnicrobiological
examination, the patient is asked to pass sorne urine into the
toilet. Then, without interrupting the flow, the next part is
directed into a special cotttainer, and the remainder into the
toilet; hence the term rnidstream specimen of urine (MSU). Fi
If it is necessary to store the specimen, it should be kept I
I
ar
at 4oC. To exclude contamination, fine-needle suprapubic * si-

aspiration of a full bladder rnay be required.

Blood tests
Creatinine is a breakdown product of skeletal muscle and
serum levels do not begin to rise until the glornerular fii-
tration rate (GFR) is halved. Creatinine clearance cau be
used to estimate GFR. Patients with chronic renal clisease
often have disordered erythropoiesis leading to normocytic,
normochrornic anaemia in addition to disordered calciurn
rnetabolism. The erythrocyte sedirnentation rate (ESR) can
be markedly raised in idiopathic retroperitoneal fibrosis,
a cause of ureteric obstruction. Hurnan chorionic gouado-
trophin (HCG), cr-fetoprotein (AFP) and prostate-specific
antigen (PSA) are usefui tumour markers.
lntravenous urography (lVU)
abdomen and pelvis is obtained to
A plain X-ray of the
outline the areas of the kidneys, ureters aud bladder (KUB
film). The iumbar spine and pelvis, as well as stones in the
region of the urinary tract, will be shown. An intravenous
urogram (IVU) involves iniecting iodine-contaiuing contrast
material intravenously and taking serial X-r'ays (Fig. 23.2) to
demonstrate the renal pelvis and calyces, the rate of kidney
emptying, the calibre of the ureters and the bladder outline
Once the bladder has filled, a 'post-micturition' film will
demonstrate bladder emptying and the amount of residual
urine.
Ultrasonography
This is another means of first-line imaging (Fig. 23.3),
tending to give superior information about the renal paren-
chyma but less about the collecting system. It also allows
visualization of other related organs, such as the liver,
spleen and gynaecologicai organs.
GT Urogram
The IVU is largely becoming superceded by the 'plaiu'
CT KUB, a non contrast enhanced CT, which has a higher
specificity and sensitivity for the detection of renal and
400 ureteric calculi. Furthermore, CT urography allows the
I
Fig,.23.2 Normal intravenous urogram (lVU).
ureters to be delineated by contrast, as in an IVU, but
also a11ows other structures within the abdomen to be
assessed.
Special radiological investigations
In certaiu circumstances a retrograde ureteropyelogram
rnay be necessarv. This involves retrograde injection of con-
trast material through a catheter placed in the lower ureter
(Fig. m.a). Abnonnalities of the renal vessels can be demon-
strated by renal angiography. Computed tomography (CT)
is now the preferred method for irnaging renal tumours.
A micturating cystourethrogram (MCU) will outline the
blaclder, detect ureterovesical reflux and examine the blad-
der neck and urethra. The bladder is filled with contrast
rnaterial (via a catheter) and emptying is then studied by
X-ray screening. An nscettditre urethrogram, in which con-
trast medium is injected into the urethra, can be used to
define strictures. When used in conjunction with a MCU, a
dascetding urethrogram can also be obtained.
Nuclear imaging
Radio-labelled substances are used for two main purposes
7. Detectittgbony nrctostases front cnrcinomn of tlte prostate
(b o n e sc nn).
"'Tc-1abeiled methylene diphosphonate
(MDP) is the rnost reliable method.
2. Mensurentent of renal fitnction (scitttigrnpltic
renograplry). Occasionally'how a kidney looks'
does not correlate with'how it behaves', e.g.
hydronephrosis does not always mean the presence LA
of obstruction. Renography allows assessment of
obsiruction to a kidney (e.g. from a pelviureteric Fig
obstruction), differential kidney function (i.e' how pyE
 Uro ogrcal sLrrger\

'.r>)
)---J-Hitum: catyces
and collecting
system, lat, FluidJilled
blood vessels cyst

Fig. 23.3 Renal ultrasound. I p

n
Normal kidney. @ A simple cyst occupies the upper pote of an otherwise normat kidney, The renal pelvis and calyces
are dilated by a chronic obstruction to urinary outflow. The thinness of the remaining renal cortex indicates chronicity
@, @anO flfhe diagrams beneath
show the anatomical features.
I

E iB]

.'U, but
:. to be

.logram
:. trf con-
=l Llreter
lemon- lnterureteric bar
:rv (CT)
*mours.
^ / ,-Uretericorifice
:-ine the
::e Lrlad-
:ontrast
:Jiec1 by
)n
':;h con-
-.rsed to
\ICU, A

::poses:
'- : ,t,1tc

: -.nate

a>ence
Catheters
:: rlf
::tc Fig.23.4 Retrogradeureteropyelography.@Cystoscopeandureterccathelerzation.BThebestviewsotthenormal collectingsystemareshownby
pyelography.Acatheterhasbeenpassedintotheleftrenalpelvisatcystoscoo: r-eanemone-likecalycesaresharp-edgedandnormal. 401
hor'v
 SURGICAL SPECIALTIES

much each kirlnev is contributing to overall function), uric acid should be rneasurerl. Ii rnore detaiied investigation trar
assess non-functior-ring areas of renal parenchyma is required a 24-hour collection of urine for determination r-uir
(e.g. scarring) ancl allor'r' accurate assessment of of calcium, phospl-rate, oxalate and uric acid excretion can refl
GFR. Radio-labelled r.nercaptuacetyltriglycine be obtained. The cornposition of passed or removed stones
(MAG-3) has largelv superseded technetium labeled should be analysed to deterrnine their metabolic type.
Rt
diethylenetriamine pentaacetic acid (Tc-DTPA)
for dynamic scanning. It is secreted from the
renal tubules and is used in the identification of Sit
obstructed kidneys and to assess differential function. Tht
Dirnercaptosuccinic acid (DMSA) is concentratecl in alla
the renal tubules and static imaging can be carried USL
out some 2-3 hours after injection. Parenchymal
Anatomy coll
defects such as scars, haematomas, iacerations or cha
The two kidneys lie retroperitoneally on the posterior
ischaemia may be demonstrated. Differential renal
abdominal wall. Each is approximately 12cm long, 5cm
function can be quantified from measuring the DMSA Po
wide and 3 cm thick. The upper pole of the kidney lies on the
concentration/density in each kidney. An
diaphragm, which separates it from the pleura and the 11th
and 12th ribs. Below this, it lies on the psoas, quadratus lum- kid
Urodynamic studies borum and transversus abdominis muscles from medial to life
The maximum urinary flow rate during micturition can be lateral (Fig. 23.6). Anteriorly, the right kidney is covered by ferr
measured using a flow meter when the voided volume is the liver, the second part of the duodenum and the ascend- cau
at least 150ml or the values may be misleadingly low. The ing colon. The spleen, stomach, tail of pancreas, left colon
norm in males is 15-30m1/s and in fernales 20-40m1/s and srnall bowel overlie the left kidney. The renal hilum lies
Br
and a flow rate of less than 10m1/s is abnormal. The flow medially and transmits from front to back the renal vein,
rate pattern can help to determine the cause of obstruction renal artery and renal pelvis. The ureter begins at the renal
Rer
(Fig. 23.5). Measurements of flow rate can be combined with pelvis and runs for 25cm to the bladder. The abdominal
i,rg
cystometry to provide a rrleasure of residual urine, bladder ureter lies on the medial edge of the psoas muscle, which
capacity, the capacity at which a desire to void occurs, and separates it frorn the tips of the transverse processes. It then
the detrusor pressures when the bladder is full and during crosses the bifurcation of the common iliac artery, which Nr
maximum flow. Spontaneous detrusor contractions during separates it from the sacroiliac joint, to enter the pelvis. The
bladder filling may indicate an unstable bladder, a cause o{ pelvic ureter runs on the lateral pelvic wall to just in front of Ep
urgency and urge incontinence. the ischial spine, when it then turns medially and forward
to enter the bladder. In the male, it is crossed by the vas Thi
deferens. In the female, it lies close to the lateral fornix of an !i
Semen analysis n'it
the vagina aud is crossed by the uterine vessels, where it is
Microscopic examination of the semen is a basic investiga- vulnerable to damage during hysterectomy. The section of ral'
tion in infertile males. The specimen is collected following ureter that lies within the bladder wal1 functions as a flap re11,
a period of abstinence of at least 3 days ancl is examined valve to prevent reflux. Stones tend to irnpact at the three mal
within 2 hours. Normal semen has a volume of > 2ml and a points where the ureter narrows: namely, the pelviureteric coI
sperm concentration of > 20 x 1'06 /rnl. More than 50% of the junction, the pelvic brim and the ureteric orifice. pre
sperm should be motile at 2 hours. The morphology, bio-
chemistry and viability of the sperm may also be studied. In cti
selected cases, immunoiogical tests may help to determine Physiology The
the cause of infertility.
ullt
The healthy kidney can produce between 0.3 and 17ml ina
Biochemical screening for stones of urine per minute, depending on the state of hydration,
Recurrent urinary tract calculi should raise the suspicion of but on average produces 1ml of urine per minute. This is lnr
hyperparathyroidism, idiopathic hypercalciuria, hyperox-
CT
aluria or cystinuria. Serum calcium, phosphate, oxalate and
Diaphragm sta!
lnferior vena cava nal
.9.
a Costal margin asl
o ere,
! Ureter overlies
c Normal flow
transverse
0)
(! - Prostatic or bladder processes of Mz
E - neck obstruction lumbar spine The
E(g
Urethral stricture Transversus foll,
o
o
a
- abdominis siot
Ouadratus Per
E lumborum oft
0)
(d Psoas reg:
E
r Time
Ureter overlying
bi{urcation Rt
of common
iliac artery Bladder
Fi9.23.5 Urinary tlow rates. The normal flow rate shows a rapid rise
Ep
to maximum high-peak flow. ln a typical bladder outflow obstruction due to
Ureter overlying Thi,
benign prostatic hyperplasia, there is a slow rise to p00r max mum flow rate
sacroiliac joint colI
and prolonged variable flow. ln a typical urethral stricture, there is prolonged
402 flow with little variability, giving a plateau- or box-shaped curve. Fig.23.6 Anatomy of kidneys and ureters. is1
 Uro ogica sLrr!-i' .

transFri::i.t i..'... :t iile ureter br- -1-J ptrist.rlti. i,. ar'.. :..r Iiis uncomrnon before the age of 40 years and has a ps2l<
rninute to re.t.h the blacller $'here it is strrrer-1 rr ithtrr.rt trrcirlence beti,r.een 65 and 75 years of age. There carr be
refluxing ulr the Llreters. spread itlto the renal pelvis, causing haematuria. Inr.asion
of the rer-ral vein, often extending into the inferior r.en.-r
Renal cysts cava/ can also occur. Direct spr.ead into perinephric tissue:
is cornmon, so that the whole fascial envelope ar-rci kirlnei
should be removed en bloc. Lymphatic spr:ead occur= t.-
Simple cysts para-aortic nodes, but blood-borne metastases (n.hich ur..ri.
These.are usually single, almost always asymptomatic, be solitary) may develop almost anywhere. Ii the lun*-
and often found incidentally on ultrasound wliere they can these characteristically give the appearance of,carrnon L,all
usually be differentiated fiom carcinorna. Cornplex cysts metastases.
containing multiple septa raise the suspicion of malignant
change
::erlOl Glinica! features
i. li clrl
: rrr the Polycystic kidney disease The triad of pain, haematuria and a mass is an important,
::.e 11th An autosomal dominant congenital anomaly affecting both albeit late, feature occurring in only 15% of .aser.
kidneys that often leacls to chronic renal failure in middle Historically, 60% present with haematuria, 40% with loin
-. iu r-n-
pain and only 25% with a mass, but increasing access to
=::ial to life. Despite their very large size, the cystic kiclneys cause
::et'l bV few symptorns. Infection or bleeding rnay occur in a cyst ultrasonagraphy and CT has increased inciden[al c-liagno-
:::aend- causing pain or haematuria. sis. Patients may present with pyrexia of unknown origin,
raised ESR, polycythaemia, disorders of coagulation, inci
-: colon
,:m lies abnonlalities of plasma proteins and liver function tests, or
-..1 vein, Benign tumours with neuromyopathy due to secretion of renin, erythropoi-
:.e renal etin, parathormone and gonadotrophins.
Renal adenomas are small and are usually an inciclental find-
: -.r-ntnal
ing. Haemangiorras are a rare cause of diamatic haematuria.
,

'.
rr-hich
. It tllen
rr'hich
is. The
Nephroblastomas
lnvestigations
The initial investigation is ultrasound, followed by a staging
contrast CT of the abdornen and chest (Fig.2J.7).
n
I
:ltrnt of
:-.nr'ard
Epidemiology
:te vas This tumour usually occurs in chilclren uncler 4 years of age,
Management
-- lrix of and is the most common childhood urological malignancy, Organ confined renal adenocarcinoma should be treated
-ere it is with an incidence of 7 per million children per year. Growth is with curative intent, either by laparoscopic or open neph-
.:tion of rapid and there is early local spread, including invasion of the rectomy. Metastatic renal adenocarcinorna is r.elatively
r= a flap renal vein. Invasion of the renal pelvis occurs late, and so hae- raclio and chemoresistant. Immunotherapy, in the forrn of
:.e three maturia is seen in only 15% of cases. Distant metastases rnost interferon, gives a modest survival benefit (3_5 rnonths)
:':reteric cornmonly appear in the lungs, liver and bones. Tumours but angiogenesis inhibiting drugs, such as tyrosine kinase
presenting in the first year of life have a better prognosis. inhibitors, are showing more promising results. A further
rnodest survival benefit may be seen in metastatic disease bv
Clinical features reducing the tumour burden if nephrectomy is performed
prior to starting immunotherapy.
The cardinal sign is a large abdominal mass. Sorne of the
unusual clinical features associated with a renal carcinoma
r-l 17m1
in adults, such as fever or hypertension, may be present.
lr.-rtion,
Tliis is
Investigations
CT of the abdomen and chest is essential for diagnosis and
aohragm staging. The main differential diagnosis to consider is adre-
nal neuroblastoma, but other causes of a large kidney, sucl-r
as hydronephrosis and cystic disease, mustilso be consici_
ered. The tumour is bilateral in 5-10% of cases.

Management
The diagnosis is confirmed by biopsy. Chemotherapy is
followed by transabdominal nephrectomy with wicie exci-
sion of the mass. Further chemotherapy + radiotherapy is
performed dependent upon the histopathological featur.es
of the removed tumour; the S-year survivai iate is ir-r the
region of 70-90%.

Renal adenocarcinoma

Epidemiology
Fil.23.7 Contrast-enhanced CT of renal cancer. The right kjdney
This tumour arises from the renal tubules and is the most s .,:a:ded by a low-density cancer that fails to take up the contrast,
common malignant tumour of the kidney. The it-rciclence , seen extending into the renal \/ein and inferior vena cava
is 16 cases per 100 000, being twice as cofirmon in males. ,.--,-' 403
 SURGICAL SPECIALTIES

tlre forrrr.rtiotr PrLtr'lllct is rlescribecl as being suytersnturoted. a It !-.

ts $ tr*ro*YBox23.1 The abilitv of urrne to keep cor-npounds in solution, and pre-

vent calculus forrnation is a balance between forces keep-
turc
is .t'
Renal carcinoma ing the solute in solution ancl those that promote nucleation. dll ri
. Renal adenocarcinoma is the most common malignant
Tl-rerefore, stones forr-n lt,hen the amount of solute increases rle1.
(e.g. hvpercalcuria), the amount of solvent decreases (e.g. rlett
renal tumour and is twice as common in males
. The carcinoma arises in the renal tubules and spreads
dehydration) or the concentration of inhibitors falls (e.g.
early to the renal pelvis, producing haematuria. Later
decreased citrate excretion). Foreign bodies, anatomical Ma
abnormalities, and calculi can all act as a nidus for nucle- Slr:.
spread involves the renal vein (with bloodstream
ation and promote further stone formation.
dissemination), perinephric invasion and lymphatic spread 11i.r.
. The clinical presentation is very varied. The triad of pain, Types and causes of stone formation ster
haematuria and a mass may be late features, and early Lret:
systemic effects include fever, polycythaemia, disordered
The cornrnonest stone types are; calciurn oxalate (85%), OLlS
uric acid (10%), rnixed calciurn phosphate/caicium oxalate sllta
coagulation and pyrexia of unknown origin
o (10%), magnesium arnmonium phosphate (5-15%) and cys- pas:
The key investigations are ultrasonography, chest X-ray
tine (1%). Calcium oxalate stones are cornmonly caused by ofc
and contrast CT
. hypercalciuria, hypercalcaemia, hyperoxaluria or hypoci- n'ht
Treatment consists of radical nephrectomy; the tumour is
traturia. Uric acid stones are formed due to increases in uric neJ
not radiosensitive. The natural history of renal carcinoma
acid formation either t}rrough gout or myeloproliferative tecl'
is very variable and excision of solitary metastases may
disordels. Approxirnately 50% of patients with urate stones stor
be worthwhile.
lrave gout but orly 20% of patients with gout develop urate teri.
stones. Calcium phosphate stones are generally secondary soul
to renal tubular acidosis. Magnesium ammonium phos- visi,:
phate (struvite) stones are usually due to urinary tract infec- (ure
Renal and ureteric calculi tion by pathogens that can break urea down into CO, and ren)
amuronia, thereby alkalinizing the uline. to l'
Mechanism of stone formation tur e

A in a so/zrenf to form a solutiott but when

sttlute dissolves
Glinical features r,isi,
the concentration of solute in solution leaches a certaiu Renal pain, renal colic and ureteric colic are characteristi- PC)
1evel, termed the solubility product, the compouucl pre- callv unilateral. Renal pain is dull and aching, whereas ure- trac
cipitates out to form crystals. This initial crystal forrnatior-r teric colic is acute and severe, occurring in waves. A stone to sr
may cause bleeding or there may be symptoms of urinary dec,
Qurclcntion) may Lrrogress such that crystals clump together
(nggregntion) to fonn calculi. There are substances in uriue tract infection. However, a stone in the kidney rnay retnaiu teri,
that act to keep compounds in solution by inhibiting nucle- silent, even one large enough to fill the pelvis and calyces anrl
ation (iiltibitors) but, above a certain concentration of solute, ('staghorn' calculus). desi
nucleation will occur despite their presence (fortnntiort prod- tota
act). Where the collcentration of a compound lies between
lnvestigations
the solubility product and the formation product, being kept IVU or CT KUB provides a1l the necessary information on Uf
in solution solely by the action of inhibitors, it is described the position of the stone (Fig. 23.8). Routine hematological
as being nrctnstnble. A solution with a concentratiou above and biochemical tests are needed to assess renal function Obs
caLl:
E tr lyce
juuc
i.g
bloc

Pe
(ic

Nar
urei
o1o5
aPp

#q
*: i
L t q
Fig. 23.8 IVU showing ureteric stone. E fighty percent of stones are visible on a plain X-ray (arro$. flhe contrast excreted by the kidney in an IVU
404 clearly shows the obstruction caused by the stone in the ureter (anow),
 Urological surgery
-::. '.;:4.;. and to erclude metabolic causes. A urine sample is cui-
--: --- l.r i.:;. ,' . ::-, .-, +r:'
! *ro,1 c.#i#,i ii tadi"qMufioilt
.
tured to deiermine n'hether there is infection. If oLstruction
- reep- is acute, iis relief is the prime clinical need; if it is chronic
:-e:ion. and has caused renal damage, the surgical approach Extrinsic
:.areases depends on the function of the affected kidnev. this is best . Retroperitoneal fibrosis
_.€s Le.g. determined by radioisotope methods (renography). . External pressure (e.9. carcinoma of the cervix, prostate)

rtomical Management
,. nucle-
Symptomatic treatment should be instituted as soon as the
diagnosis is confirmed. Intramuscular diclofenac, a non-
n steroidal anti-inflammatory, is the most effective analgesic;
pethidine is an alternative. The likelihood of spontane_
: rE5oo), ous passage depends on the size of the stone and on its
: o\alate smoothness. A stone less than 0.5cm in diameter should
and cvs- pass. Immediate treatment should be considered in cases
,used by of- ongoing pairy renal obstruction or, more importantly,
l1\'Poci- where there are sig"ns of sepsis (infected obstructed kid-
5 in uric
ney). Extracorporeal shock-wave lithotripsy (ESWL), the
terative technique of focusing external shock waves to break up
:e stones stones, has revolutionized the treatment of renal and urei_
.rp urate teric stones. If a stone can be visualized on X-ray or ultra_
rondary sound, then it can be treated by ESWL. Other stones can be
Tl Phos- visualized directly by passing a fine telescope up the ureter
lct infec- (ureteroscope) and the stones may be either broken up or
CO. and removed intact. Some stones in the kidney that are unlikely
to pass even if broken up are best treated by direct punc_
ture of the kidney, insertion of a sheath and removal under
:Ii?11.w_ith
a nepfu oscope (percutaneous nephrolithotomy,
acteristi- PCNL). It is now very rare to remove stoneJfrom the renal
aeas ure- tract at open operation. In cases of acute obstruction leading
-\ stone to sepsis (infected obstructed kidney) or renal impairment,
'urinary decompression of the kidney eithei via insertion-of a ure-
; remain terrr stent or percutaneous nephrostomy is required. Stones
I calyces and infection within a kidney can be the ciuse of renal
destruction and if the kidney contributes less than 10% of
total renal function, then a nephrectomy is recommended.
ation on
:ological
Upper tract obstruction
runction
Obstruction may be due to extrinsic, inhinsic or intraluminal
causes (Table 23.1).In the kidney, stones within the pelvica_
lyceal systemand a congenital abnormality of thepelviureteric
junction (see below) are the main causes of obskuction lead-
ing to hydronephrosis. More rarely, a sloughed renal papilla
blood clot or fumour may be the cause.
Pelviureteric iunction obstruction
(idiopathic hydronephrosis)
Narrowing o,,n" ;rr.,"rro.ffi
ureter is a colrunon cause of hydronephrosis. As the aeti-
ology is obscure, the term'idiopathicr hydronephrosis is
appropriate. This condition is seen in very young children.
lntrinsic
o Transitional cell tumours
. Tuberculosis / schistosomiasis
. Ureterocoele
. Ectopic ureter
It is likely to be congenital and can be bilateral, but gross
hydronepfuosis may present al arly age.
Clinical features
Idiopathic hydronephrosis may produce a large painless
mass in the loin; in its grossest form, the volume of urine in
the hydronephrotic sac may simulate free fluid in the peri_
toneal cavity. The more usual moderate hydronephiosis
causes ill-defined renal pain or ache that may 6e exacerbated
by drinking large volumes of tiquid (Dietls, Crisis). The
patient may regard these symptoms as,indigestion,. Iiarely,
aYt
there may be no symptoms. 47
I
sffi
lnvestigations ffi
IVU or a CT urogram (CTU) provides sufficient informa-
w
ffi
tion in many cases. The calibre of the ureter is normal. There ffiffi
are a few patients in whom there is doubt as to whether the
w
,r.wlff
dilatation of the pelvis and calyces is truly obstructive in r1-::-tl;',r
nature. In these cases a MAG-3 renogram is performed.
Management
Either laparoscopic or open pyeloplasty is performed to
remove the obstructing tissue and refashion the pelvi_
ureteric junction (PU) so that the lower part of the renal
pelvis,drains freely into the ureter (Fig. 2g.g). It is not
possible to predict the degree of recovery of renal function
after the relief of obstruction, but a kidney contributing less
than 10% of total renal function should be removed.
Retroperitoneal fibrosis
Pathology
Fibrosis of the retroperitoneal cormective tissues may encircle
and.compress the ureter(s), causing hydroureter and hydro-
nephrosis. Fibrosis occurs in three groups of conditions:
. Idiopathic. The aetiology is unknown, although it may
be associated with methysergide or analgesii abuse

- an lvu
Fig. 23.9 Anderson-Hynes pyeloplasty. 405
T SURGICAL SPECIALTIES
Mediastinal fiLrrosis and Dupuytren's contracture
,n .
may coexist
Malignnt itr.filtrttiorr. The fibrosis contains malignant
cells that have metastasized from primary sites such as
the breast, stomach, pancreas and colon
. Renctiae fbrosls. Radiotherapy, resolving blood c1ot, or
extravasation of sclerosants can lead to fibrotic change
in the retroperitoneum.
As the gross appearance of fibrosis in all three grouPS may
be simiiar, biopsy of the tissue is essential for diagnosis.
Clinical features
Ureteric obstruction may cause symptoms similar to
idiopathic hydronephrosis: narnely, ill-defined renal pain
or ache, and low backache.
Investigations
IVU or CTU shows hydronephrosis and usually hydroureter
down to the level of the obstruction. The ureter is often dif-
ficult to define, but it is usually pulled medially. A mark-
edly raised ESR is found in more than 50% of cases with
idiopathic fibrosis.
Management
Relief of obstruction may be difficult. Where ureteric
stenting fails io give adequate drainage uretrolysis can be
performed; the ureter is dissected out of the fibrous sheet of
tissue (ureterolysis) ar-rd wrapped in omentum to prevent
further involvement.
$ rr**o*rBoxz,.2
Urinary tract obstruction
Common causes 0f obstruction of the lower 0utflow tract
. Benign prostatic hyperplasia
. Prostatic cancer
. Bladder cancer involving the bladder neck
. Bladder-neck obstruction (dyssynergia, infection,
neurological disorders)
. Urethral obstruction (congenital posterior urethral valves,
blocked urinary catheter, trauma, infection, stricture).
Common causes of obstruction of the upper urinary tract
.Renal and ureteric calculi (80% are calcium oxalate/
phosphate stones)
r Pelviureteric junction 0bstruction (idiopathic hydr0nephrosis)
o Retroperitoneal fibrosis (idiopathic/malignant infiltration/
radiotherapy)
. Transitional cell carcinoma (with or without bleeding and clot)
. Congenital abnormalities (e.9. ectopic ureter, ureterocoele)
. lnfections (notably schistosomiasis and tuberculosis).
Anatomy
The bladder is a muscular reservoir that receives urine via
the ureters and expels it via the urethra. In children up to
4 years of age, it lies predominantly in the abdomen; in the
adult it is a pelvic organ, well protected in the bony pelvis.
Superiorly, the bladder is covered with peritoneum, which
separates it from coils of small bor,vel, the sigmoid colon
406 and, in the female, the body of ihe uterus. Posteriorly 1ie
the rectum, the vas deferens and seminai vesicles in the
male, and the vagina and supravaginal cervix in the female.
Inferiorly, the neck of the bladder transmits the urethra and
fuses with the prostate in the male and with the pelvic fascia
in the female.
The bladder is composed of whorls of detrusor muscle,
which in the male become circular at the bladder neck. They
are richly supplied with sympathetic nerves that cause
contraction during ejaculation, thereby preventing semen
from entering the bladder (retrograde ejaculation). There is
no such sphincter in the female. The bladder is lined with
specialized waterproof epithelium, the urothelium. This
is thrown into folds over most of the bladder, except the
trigone where it is smooth.
The male urethra is 20cm long; the prostatic urethra
descends for 3cm through the prostate gland, and the mem-
branous urethra is 1-2cm long and intimately associated
with the main urethral sphincter, the rhabdosphincter. The
spongy urethra is L5cm long and is surrounded by the cor-
pus spongiosus throughout its complete length, opening on
the tip of the glans penis as the external meatus. The spongy
urethra is further subdivided into the proximal bulbar ure-
thra and the distal penile uretfua. The female urethra is
3-4crn iong, descending through the pelvic floor surrounded
by the urethral sphincter and embedded in the anterior vagi-
nal wa11 to open between the clitoris and the vagina.
In the male, the prostate is pyramidal, with its base upper-
most. It resembles the size and shape of a chestnut and
surrounds the prostatic urethra. Traditionally described as
having a median and two lateral lobes, it is better cor-rsidered
as being composed of a smalI central and a larger peripheral
zone (Fig. 23.10).
Physiology
Neurological control of micturition
Detrusor contraction is mediated through cholinergic para-
sympathetic nerves arising from the nerve roots S2-S4, and
relaying through ganglia lying predominanily within the
detrusor. Sympathetic nerves arise from T10 to L2 and relay
I
via the pelvic ganglia. Tl-reir exact role in the conhol of mictu-
rition is unclear. It is known that o-adrenergic receptors and
i:
t,
their nerve terminals are found mainly in the srnooth mus-
cle of the bladder neck and proximal urethra. The o-receptors l'
respond to noradrenaline (norepinephrine) by stirnulating
E
f-
contraction, thereby maintaining closure of the bladder neck.
i:
The distal sphincter mechanism is
innervated frorn
tl
the sacral segments 32-54 by somatic motor fibres that 1t
reach the sphincter either by the pelvic plexus or via the
tt
pudendal nerves. Afferent nerves are carried in both the
parasympathetic and pudendal pathways and transmit
sensory impulses from the bladder, urethra and pelvic floor. E
These sensory impulses pass to the cerebral cortex and the T
micturition centre, where they produce reflex bladder relax- :
ation and increased tone in the distal sphincter, so help- :t-
ing maintain continence. Cortical control is a basic part of
the micturition cycle described beiow. The higher centres i,.
suppress detrusor contractions and their main function is to '-: l
inhibit micturition until an appropriate time.
The micturition cycle t,
The micturition cycle has two phases.
It:
Storage (or tilling) phase I'
Due to the high compliance (elasticity) of the detrusor tl:
muscle, the bladder fills steadily without a rise in intra-
vesical pressure. As urine volume increases, stretch
 Urological surgery

s in the
,female. E
tra and
ic fascia
Uterus
muscle,
:k. They Bladder Rectum
]t CaUSe
i semen Symphysis pubis
There is
red with
Urethra ijf:1,'rr
m. This t:i:l;il
cept the

urethra
he mem-
isociated
rter. The tr
'the cor-
ening on
3 sPongy Bladder
lbar ure-
Symphysis pubis
rethra is Seminal vesicles
rounded Prostate
rior vagi- Corpus cavernosum
Prostatic urethra
I.
Bulbar urethra CI
€ upPer-
tnut and Penile urethra
Rectum
A
I
ffibed as
,nsidered Corpus spongiosum Vas deferens :iql;;
:,:
eripheral
Epidldymis
Grans penis
---l Testicle

Scrotum
Fig. 23.10 Anatomy of the lower urinary tracts. E Femate, E Mate.

'glc Para-
l-S-1, and
ithin the
and relay
receptors in the bladder wall are stimulated, resulting
of mictu-
ptors and
in reflex bladder relaxation and reflex increased sphinc- Trauma
ter tone. At three-quarters of bladder capacity, sensation
nth mus- produces a desire to void. Voluntary control is now
-receptors
exerted over the desire to void, which temporarily disap-
Bladder
imulating pears. Compliance of the detrusor allows further increase Open injuries
der neck.
in capacity until the next desire to void. Just how often The bladder may be damaged as a result of a penetrating
ted from this desire needs to be inhibited depends on many factors, injury to the lower abdomen, or through the course of pelvic
ibres that
not the least of which is finding a suitable place in which surgery; during which damage to the urethra, rectum,
rr via the to void. vagina or uterus may also occur. Unrecognized damage
both the during surgical procedures may lead to a wound fistula, a
transmit vesicovaginal fistula or a vesicocolic fistula.
:llic floor. Emptying (or micturition) phase
x and the The act of micturition is initiated first by voluntary and then Closed injuries
lder relax- by reflex relaxation of the pelvic floor and distal sphincter Intraperitoneal rupture typically occurs in a patientwho has
. so help- mechanisms, followed by reflex detrusor contraction. These been drinking alcohol, has a full bladder and is assaulted
iic part of actions are coordinated by the pontine micturition centre. and kicked in the abdomen. The dome of the bladder rup-
er centres Intravesical pr"ssure remai.r, greater than urethral pressure tures and urine extravasates into the peritoneum, causing
rction is to until the bladder is empty. intestinal ileus and abdominal distension. Extraperitoneal
The normal control of micturition requires coordinated rupture is usually due to a major road traffic accident in
reflex activity of autonomic and somatic nerves, as descri- r,r,hich the pelvis has also been fractured when the bladder is
bed above. These responses depend on normal anatomical not full, but may follow endoscopic resection of the prostate
structures and normal innervation. There are thus tlvo or a bladder tumour (Fig.23.11).
main types of disorders of micturition: structural and neu-
rogenic. Examples are extensive carcinoma of the prostate Clinical features
r detrusor that has damaged the sphincter mechanism (structural), Ihe ileus and distension that occur with intraperitoneal
e in intra- and spinal cord injury that has damaged the innervation rupture of the bladder are often detected late because of the
s. stretch (neurogenic). circumstances surrounding the injury. However, the patient 40i
 SURGICAL SPECIALTIES

I
I
1:

\
L
Fig.23.11 Rupture ofthe bladder. @ lntraperitoneal. @ Extraperitonea
S

will be aware of the inability to pass urine and seek advice.
Extraperitoneal extravasation of urine, if part of a maior
accident, adds to what already are severe pelvic injuries.
When the leak occurs during an endoscopic procedure, the
patient later complains of suprapubic pain with varying
lnvestigations t-
If the physical signs suggest an anterior urethral injury, and
the patient has passed clear urine, no further steps need be
taken. If there is blood at the external meatus or the urine is
S
blood-stained, a urethrogram using water-soluble contrast L:

degrees of lower abdominal tenderness. ti

material rnay demonstrate the extravasation (Fig. 23.1,2).
a
lnvestigations A catheter should never be passed in the emergency room.
Generally, the circumstances of the bladder iniury establish If urine is blood-stained, retrograde urethrography may 11

e
the diagnosis. If confirmation of injury is required, water- be carried out but the radiological distinction between a
n
soluble contrast is injected via a urethral catheter and the rupture of the membranous urethra and an extraperiioneal
bladder rupture may be difficult. ti
bladder examined on the X-ray screen (cystograrn). o
Management S1
Management
Intraperitoneal rupture demands laparotomy and repair.
All patients with an injury to tl-re bulb of the urethra have Ie

a perineal haematorna. If the injury is only a contusion, a

Extraperitoneal rupture in the absence of other injuries
this will resolve, but prophylactic antibiotics are indicated. c
tends to be managed conservatively through drainage of the
A large haematoma may require drainage if the urethra has
bladder with a urethral catheier left in situ for 6-10 days.
been lacerated. The extent of injury should be defined and B
Occasionally, surgical exploration is required.
t1'

d
Urethra
Open injuries
Penetrating injuries resulting in damage to the anterior or
posterior urethra are rare.

Closed injuries
Damage to the anterior urethra is typically due to falling
astride a hard object, although a kick can cause a similar injury.
The mechanism of injury to the posterior urethra is similar to
that of extraperitoneal rupture of the bladder. In the majority
of cases, posterior urethral injuries are associated with a frac-
ture of the pubis or fracture-dislocation of the pelvis. Both the
posterior urethra and biadder are damaged in 10% ofcases.

Clinical features
Anterior urethral injuries are usually located at the bulb,
so that the patient presents with a perineal haematotna.
If this becomes infected, there may be sloug1-ring of the
skin, urethra and even the scrotal tissues. Because of
the mechanism of injury, patients with posterior ure-
thral tears are usually shocked and require resuscitation
before a detailed assessment can be made. If the patient
has passed clear urine, the bladder and urethra are proba-
bly intact. If there is blood at the external meatus, urethral
injurv must be suspected. A distended bladder can occur
because of spasm of the urethral sphincter or because of a Fig.23.12 Ascending ureterogram in urethral rupture. Contrast is
408 torn posterior urethra. seen extravasating at the site of the disruptecl urethra (arrow).
 Uro ogrca sLrr3,.

the urethra repaired if possible. A urethral or suprapubig

q catheter drains the bladder. Treatment of a posterior urethra1 Tg"
injury depends on the expertise available. It is quite accept-
able to perform a suprapubic cystostomy and deal n,itl-r the Tso

injury to the urethra at a later date. If laparotomy is neces-

sary for other reasons, t1-ris rnay give an opportunitv to pass
a catheter. If the rupture is incomplete, the catheter will act
as a splint. If the rupture is complete, the ends of the urethra
can be approximated and splinted by the catheter. The late
complications of these injuries are stricture and impotence.

Bladder tumours

Pathology
The vast majority of bladder tumours arise from the urothe-
lium or transitional cell lining, which it shares in contirtuum
with the renal pelvis and the proximal urethra. The urothe- Fig,23.13 T categories of bladder tumour. (Cis = carcinoma in situ)
lium is exposed to chemical carcinogens excreted in the urine,
such as naphthylamines and benzidir-re, which were exten-
sively used in the chemical and dye industries in the past. The (sfage). The TNM system of tumour classification is applica-
bladder is more susceptible to urinary carcinogens, as urine is ble to bladder tumours. Assessment of the primary tumour
stored in the bladder for relatively long periods of time. (T) is of prime clinical importance and requires bimanual
'-rrr', and
Almost all tumours are transitional cell carcinomas. examination under anaesthesia to judge the degree of pen-
, neecl be
Squamous carcinoma may occur in urothelium that has etration through the bladder wall. This is especially impor-
.. urine is

:
;trutrast
)i.12).
:a\' IOOm.
undergone metaplasia, usually due to chronic inflamma-
tion or irritation caused by a stone or schistosomiasis. An
adenocarcinoma is a rarity but may occur in an urachal rem-
tant for T, and T. tumours (Fig. 23.13). Clinical examination,
urography and CT are used to assess the involvement of
regional and juxtaregional lymph nodes (N). Assessrnent
x
I
nant in the dome of the bladder, or from iocal infiltration, of distant metastases (M) requires clinical examination and
:hv may
e.g. bowel cancer. The prevalence of transitional cell carci- CT. Histopathological examination guides the choice of
atrfeen a
treatment. Biopsy gives accurate information on superficial
noma in the bladder is 45 cases per 100 000, and it is three
'eritoneal tumours, but depth of invasion of invasive tumours cannot
times rnore common in men than n,omen. The appearance
of a transitional cell tumour ranges from a delicate papillary be assessed precisely as the biopsy does not examine the full
structure to a solid ulcerating mass. Papillary tumours are thickness of the bladder wall.
:rra have less aggressive superficial cancers, whereas those that ulcer-
:r-rtr-rsion, ate are much more aggressive. Clinical features
::.1icated. More than 80% of patients have haematuria, which is usu-
:ethra has
Staging ally painless (Fig. 23.14). It should be assumed that such
:'-netl and Biopsy is essential to confirm the diagnosis (cell type), deter- bleeding is from a tumour until proved otherwise. In
mine tlre degree of cell differentiation (grnde), and assess the women, symptoms of cystitis are so common that occa-
depth to which the tumour has penetlated the bladder wall sional bleeding may be thought to be part of an inJective

E tBl

{{_
I

-lntrast is
Fig.23.14 Haematuria, A : : B Macroscopic
409
T SUBGICAL SPECIALTIES
problem. Therefore, in cases of haematuria, MSSU is
mandatory with further investigation required if no growth
is found. In men, symptoms of bladder outflow obstruction
are common and may include bleeding. Bleeding at initia-
tion of micturition suggests a prostatic, or urethral, origin.
Haematuria throughout micturition suggests either a blad-
der or upper tract cause. A tumour at the lower end of a
ureter or a bladder tumour involving the ureteric orifice rrlnlT
cause obstructive symptorns. However, frank haematuria
may be the only presenting symptom. Examination is usu-
ally unhelpful. Rectal examination detects only advanced
tumours.
lnvestigations
Because upper tract tumours are much less common, they
may be overiooked in the presence of an obvious blad-
der tumour. Both may occur together, and the whole of
the urothelium must be examined on the IVU or CTU
(Fig. 23.15). If thele is any suspicious filling defect in the
ureter, a retrograde ureteropyelogram is necessary. In cases
of frank haematuria, investigations cousist of flexible cys-
toscopy, peformed under loca1 anaesthesia, and either an
ultrasound of the kidneys with an IVU or a CTU. Where a
lesion is found within the bladder, cystourethroscopy and
examination under anaesthesia are performed (Fig. 23.16).
With the patient relaxed under general anaesthesia, the
bladder and tumour are examined bimanually to determine
the depth of spread. The physical features of the tumour(s)
are noted, the normal bladder mucosa is inspected and the
tumour is fully resected if possible. If not, biopsies are taken
from the tumour and any other suspicious areas.
Management
Superficial bladder tumours (T", T,)
Ideally these are treated by formal transurethral resection
of the blabber tumour (TURBT) down to and inciuding
detrusor muscle; hor,t,ever, they can also be treated solely
by endoscopic diathermy if required. Intravesical chemo-
therapy (mitomycin C) is useful to treat multiple low-grade
bladder tumours and to reduce recurrence (EBM 23.1).
41 0 Fig. 23.15 Filling defect on IVU due to bladder tumour.
Regular check cystoscopies are required. Recurreuces are
rnosth' treated by repeat diathermy or resection but, if they
become very frequent and excessive, cystectomy may be
ac-lvisable. Carcinoma in situ (Cis) may be present in mucosa
that appears normal or in association with a proliferative
tumour. Cis can also exist as a separate entity, when there
may be only a generalized redness (malignant cystitis). Cis
should be considered in patients with ongoing irritative uri-
nary symptoms associated with pain or symptoms sugges-
tive of ongoing urinary tract infection, both in the abseuce
of urinary tract infection upon MSSU cuiture. Untreated
patients with Cis have a high risk of progression to invasive
cancer. Cis responds well to intravesical bacille Caimette-
Gu6rin (BCG) treatrnent. However, if there is any doubt
about the response, and especially if there is any pathologi-
cal evidence of progression, more aggressive treatment is
warranted.
of intavesical chemotherapv in superficial
EBM
ii;ld:lle
'A single dose of intravesical mitomycin C following
transurethral resection of a bladder tumour reduces the risk of
subsequent recurrence.'
Tolley DA, et al, J Urol 1 996; 155\4):1233-1237
lnvasive bladder tumour (Tr-Ts")
Management is controversial. For patients under 70 years of
age, radical cystectomy is recommended. In older Patients,
racliotherapy may be a better option. Unfortunately, this
may not always cure the tumour and 'salvage' cystectorny
may be needed. Cystectorny always necessitates urinary
diversion. Where the urethra can be retained, it may be pos-
sible to construct a new bladder from colon or small bowel
(orthotopic bladder replacement), so achieving continence.
Alternatively, the urine is collected in an internal reservoir
that is connected to the body surface via a continent con-
duit (ileum or appendix), through which the patient drains
the urine at regular intervals with a catheter. In less favour-
able circumstances, an ileal conduit should be performed
(Fig. 23.77). In some countries where an 'ostomy' is not
acceptable, the ureters can be implanted into the sigmoid
colon (ureterosigmoidostomy). However, renal infection
and metabolic disturbances are potentially serious compli-
cations of this procedure. An invasive Tr tumout, fixed to
the peivis or surrounding organs, is inoperable and only
palliative treatment can be given.
Prognosis
Outlook depends on tumour stage and grade. Superficial
disease carries a much better prognosis with a S-year
survival of 70-90%. Muscle invasive disease has a S-year
survival of 10-60%.
Carcinoma of the prostate
Epidemiology
In the UK, this is the fourth most common malignancy in
males, with a prevalence of 50 cases per 100 000 population,
and is increasing in frequency. It is the second most com-
rnon cause of cancer death in men in the UK. The tumour is
P
common in northern Europe and the USA (particularly in
the black population), but rare in China and Japan. It rarely A
occurs before the age of 50 and is uncommon before the 111
age of 60. The mean age at presentation is approximately If
70 years. The aetiologv is unknou'n, but genetic, hormonal na
and possibly viral factors are in-rplicated. TI
 Urorog,ca -J
L:!.1r€
: :, :ileV
::- -lI tre
- :-.:aLrs.1
..:::.-tti\'e
':r ihere
::::. , CiS PUJ obstruction
--t::', e u1i- (antegrade
pyelogram)
-..lseltce
:.:Ie.rted
::',\ asive
--..imette-
r'. .'loubt
.-.: tt L) logl-

::11etlt iS
Transitional cell carcinoma
of bladder
rficial

skof ]

Ureteric tumour

\-ears of Benign prostatic

hypertrophy
x
I
:ratients/
:el\', this
.iectomy
i Lll inary
'. L.e pos-
bowel
-..11
:tinence.
:esel voir Stone in ureter
'.er1t con- (ureteroscopy)
..t rlrains
. favour-
.-:formed
'.' is not
.igmoid
:nfection
. .or11p1i-
firecl to Urethral stricture
.:nil only
Retroperitoneal fibrosis (CT)
with dilated ureter (arrow)
jr.erficial
:. l-vear
: 5-vear

Meatal stenosi s

:iancy ln Ureterocele (lVU)

:ulation, Fig.23.16 Common pathologies of the urinary tract.
r.rst com-
::rnour is
.:rl.'rrly in
Pathology
c.rncer and many men will die with a cancer of the prostate _
. It rarely Almost all malignant tumours of the prostate are carcinrr- trut. rrot./l-orir that cancer. It is estimated that the pievalence
mas with the most common being adenocarcinoma (> 95,, ).
=fore the r-f focal histological cancer in men aged 50-75 is approxi_
'rimately If a prostate is examined by serial section, a small m.rli.t- nr.rteh' 10%, whereas the prevalence of clinical prostate
- -.rr-ttonal nant focus is detected in almost all men over the age of Sir. t.rncer is approximately 8%, one-quarter of whom will clie
Thus, there is a very high prevalence of histological prostate ir.-tu that cancer. The TNM system is used in classification 411
J SURGICAL SPECIALTIES

Ia
t-
11

I
c
r
t
L

Fig.23.17 lleal conduit urinary diversion. E and Elsolation of segment of terminal ileum. @ Fashioning of uretero-ileal anastomosis. The stoma is C

made to protrude from the skln t0 minimize skin contactwith urine and so reduce lrritation t
c
a
'Gleeson score'; (most common type + second most com-
SUMMARY BOX 23.3 mon type = Gleeson score). Therefore, Gleeson scores
r
l'l
range from 2-10 and are always expressed as an equation
Urothelial tumours
@.g.a+3=7).
o The urothelium 0r transitional cell epithelial lining of the
urinary tract extends from the renal papilla to the distal
urethra -raorc cancer
. The incidence of urothelial cancer is increasing, ! zr.2 TIrM sassfrcmon oi pros:rau
possibly because of increasing exposure to occupational
T (Tumour)

.
carcinogens, smoking and analgesic abuse . To No evidence of primary tumour
Almost all urothelial cancers are transitional cell . T* Primary tumour cannot be assessed
tumours and the vast majority occur in the bladder. . T, Tumour clinically inapparent and not palpable
Squamous cancers are rarer and are associated with . T," lncidental finding following TURP in < 5% prostate
chronic initation or inflammation (e.9. calculi and chips
schistosomiasis). Adenocarcinomas are extremely rare t lncidental finding following TURP in > 5% prostate
. Frank haematuria is present in 80% of cases
T,o
chips
o Transitional cell cancers of the bladder are treated as . T,, Prostate cancer detected by prostate biopsy
follows: . Ir^ Palpable nodule involving half of one lobe
o Carcinoma in situ (Cis) may respond to intravesical . Iro Palpable nodule involving one lobe
BCG but is unpredictable and may require more . r" Palpable nodule involving both lobes
T
aggressive treatment . T," Extracapsular extension of prostate cancer
o Superficial tumours (Ta, Tl) are usually treated by . Tro Prostate cancer involving the seminal vesicles
transurethral resection * intravesical chemotherapy . To, Prostate cancer involving the bladder neck and/or
o lnvasive tumours (T2, T3) may be best dealt with by external sphincter and/or rectum
radical cystectomy (or by radical radiotherapy) . Too Prostate cancer involving the lateral pelvic wall
o lnvasive T4 tumours with fixation to the pelvis or
N (Nodes)
sunounding organs are dealt with by palliative
radiotherapy.
. No No regional lymph node metastasis
. N, Regional lymph nodes cannot be assessed
. N, Regional lymph node metastasis

M (Metastases)
(Table23.2). Metastatic spread to pelvic lymph nodes occurs
early. One-third of clinically localized tumours at the time of
. M, No distant metastasis detected

presentation will have spread to regional nodes. Metastases

. M* Distant metastasis cannot be assessed

to bone, mainly the lumbar spine and pelvis, occur in some

. M," Metastasis to non-regional lymph nodes

10-15% of cases.
. M,o Skeletal metastasis Present

The Gleeson score is also used to grade prostate ade- ' M,, Metastasis to other sites

nocarcinoma. Cells are graded 1-5 depending upon their .Sobin

LH, Wittekind C, eds. TNl\/ classification of malignant tumours, 6th
level of differentiation (grade 1 = most differentiated, edn. Chichester: John Wiley; 2002.
grade 5 = Ieast or most anaplastic). The pathologist uses fl]RP = transurethral resection of the prostate)
+ I z the two most common malignant cell tr.pes to determine a Fi

Clinical features
The presentation of patients with prostatic carcinorna is
similar to benign prostatic hyperplasia (BPH); one-quarter
present with acute retention (Fig. 23.18). Occasionalh,, the
tumour extends posteriorly around the rectum and causes
alteration in bowel habit. Presenting symptoms and signs
due to metastases are much less common, but include back
pain, weight loss, anaemia and renal failure secondary to
ureteric obstruction. On rectal examination, the prostate
feels nodular and stony hard but many irregular prostates,
even those with nodules, are not malignant. Conversely,
50-60% of malignant prostates are not palpably abnormal
on rectal examination.
lnvestigations
As most patients present with outflow tract obstruc-
tion, ultrasound and serum cteatinine determinations
are performed to assess the urinary tract. An X-ray of the
peivis or iumbar spine (to investigate backache) may show
osteosclerotic metastases as the first evidence of prostatic
malignancy. Whenever possible, the diagnosis is confirmed
by needle biopsy, usually performed under transrectal
ultrasound (TRUS) guidance, or by histological examination
:::ma ls of tissue removed at endoscopic resection if this is needed
to relieve outflow obstruction. The patient is assessed for
distant metastases by a radioisotope scan. Prostate-specific
antigen (PSA) is the main serum marker for the detection of
lat com- prostate cancer. A PSA of < 4.5 is generaliy regarded as nor-
'! scoles mal although there has been a move to regard < 3.5 as being
jquation
^r
Fig. 23.1 8 Endoscopic view of prostate. @ Normal. p Obstruii.:
Uro ogical surger\
nornlal if less than 65 years of age. Metastatic disease is
e\.eptional rvhen the PSA level is < 15, but levels > 100 ng/
ml ah'uost alrvays indicate distant bone metastases. PSA is
the t-uain test for monitoring response to treatment and r-lis-
ease }rlogression. A bone scan may be carried out at follo$'-
ufr to localize and define the extent of metastases, r,r,hereas
CT is useful to assess pelvic lymphadenopathy.
Management
Prostatic cancer is sensitive to endocrine influences
(EBM 23.2) as testoterone is a trigger for moving prostate
cells through the cell cycle thereby stimuiating mitosis.
Management is best considered in three clinical groups/ as
follows.
Organ confined / localized disease
With increasing use of PSA, a raised value may be the only
abnormality that leads to the diagnosis of cancer confirmed
by a needle biopsy. A patient with a small focus of well-
differentiated carcinoma may be managed by an active sur-
veillance policy, as usually these patients remain unaffected
by their prostate cancer for between 10-15 years. In younger
patients with a longer life expectancy (i.e. > 10 years), or in
patients with a large tumour with a less well-differentiated
cell pattern (Gleeson score 7 or more) there is an increased
risk of progression. In these cases, treatment with curative
intent bv either surgery or radiotherapy is suggested. The
A
I
prostate can be removed laparoscopically, robotically or by
the traditional open route. Radiotherapy can be performed
by external beam radiotherapy (EBRT) or by the insertion
of radioactive seeds in the prostate (brachytherapy). There
are no data to support one treatment over the other in terms
of overall survival. However, each treatment modaiity has
a different side effect and complication profile. Therefore,
the choice of treatment tends to be based upon patient
preference. In active surveillance, patients tend to have reg-
ular PSA measurements and only undergo treatment if the
level rises.
Locally advanced disease; no evidence of bone
metastases
This term refers to cases where the prostate cancer has
invaded directly outside the prostate but has not metas-
tasized. Surgery does not confer a cure in this situation.
However, EBRT along with hormonal therapy has shown
some survival benefit. In patients not able to tolerate EBRT,
hormone therapy alone or palliative treatment can be
considered.
Metastatic prostate cancer
Approximately half of the men diagnosed with prostate
cancer will have metastatic disease. The basis of treat-
ment in these cases is castration either physically by andro-
gen depletion (orchiectomy) or chemically, by androgen
suppression (gonadotrophin-releasing hormone analogues)
andf or androgen receptor antagonists. A small number
of patients fail to respond to endocrine treatment; a larger
nurnber respond for a year or two, but then suffer disease
Lrrogression. PSA levels are a useful marker of response,
icleally falling to < 0.01 in well conkolled cases. Oestrogens
are useful but are limited by their thromboembolic effects.
Cl-rer-notherapy with taxanes has shown a marginal improve-
merrt in both symptoms and survival. Radiotherapy is an
effective treatment for localized bone pain. For severe gen-
eralizerl bone pain, intravenous 8eStrontium may give effec-
rn" basis of treatment remains pain q:
li,i,iii].:l'ilir:J:
 SURGICAL SPECIALTIES
EBM Za.Z Hormone manipulation in prostate cancer
'Reducing circulating testzsterlne levels (either by castration or
by nedication) results in a 70% initial response rate. Additional
androgen blockade produces a small increase in survival but
with poorer quality of life.'
Prognosis
The life expectancy of a patient with an incidental finding
of focal carcinoma of the prostate is that of the normal pop-
ulation. With tumours localized to the prostate, a 15-year
survival rate of 56-87% can be expected; if metastases are
present, this fal1s to < 10%. PSA is a very useful marker to
cletermine response to treatment in addition to monitoring
disease progression or recurrence.
rulrben' corrsisterro', referled to as benign prostatic hyper-
plasia (BPH). Er-rlarging adenomas lengthen and obstruct the
prostatic uretlrra, causing outflow obstruction and detru-
sor muscle hvpertrsphy. The muscle bands of the bladdel
forn-r trabeculae, between which saccules forrn diverticula
(Ft9.23.19). Occasionally, a diverticulum may become quite
large, even larger than the bladder. Bladder diverticula
empty poorly and are liable to the three main complications
of urinary stasis: infection, stones and tumour. With pro-
gressive inability to empty the bladder completely (chronic
retention), the risk of urinary infection and stone formation
increases. Eventually, the residual urine voiume rnay exceed
one litre, resulting in progressive obstruction and dilata-
tion of the ureters (hydroureter) and pelvicalyceal system
(hydronephrosis). This ultimately leads to obstructive renal
failure.
Glinical features
Frequency, nocturia, urgency, dysuria and poor stream are
common. Straining may cause vessels at the bladder neck t'
to b1eed. Clinical features may be due to obstruction (slow 1-

stream and hesitancy) and those due to detrusor instabil- I

1) rr**o*YBox2a.4 ity (urgency and urge incontinence). In isolation, the lat-
ter symptoms are not an indication for prostatectomy.
1:

Prostatic cancer
I
Increasing frequency may deceive tire patient into believ- t
. ln the UK this is the second most common cancer in ing that an adequate amount of urine is passed, whereas the c
men, presents at a mean age 0f 70, and is increasing in bladder has a small functional capacity and may be almost S

incidence full all of the tirne (chronic retention). Frequency rnay prog- tl
. The carcinoma may be incidental (i.e. found on ress to continual dribbling incontinence leading over time
histological examination), clinically apparent (bladder to signs and symptoms of obstructive uraemia, including Ir

outflow obstruction and a hard craggy prostate) or occult drowsiness, anorexia and personality changes. Urinary f
(metastatic disease) t
. Metastatic spread may occur early; one-third of clinically n
confined cancers have spread to lymph nodes, and
1 0-1 5% of all new cases have bony spread (to lumbar
Renal failure n
spine and pelvis) P
. Treatment of prostatic cancer varies: l-r
o lncidental or focal cancer lf well differentiated, then life
expectancy can be normal with a watch-and-wait policy.
s
lf the cancer c0ntains undifferentiated cells, then either
T
Hydronephrosis
1I
radical surgery or radiotherapy is considered
o Localized cancer with n0 evidence of bony metastases. al
Il.
Treated by either radical surgery 0r radiotherapy, keeping
q
endocrine therapy in reserve
o Metastatic cancer. Treated by androgen depletion
t1.

LI
(orchiectomy) or androgen suppression (gonadotrophin Hydroureter
releasing hormone analogues)
t.
lt-
o Tumours localized to the prostate and amenable to
11I
radical curative treatment have a 1 O-year survival rate
oI 60-750/o.

Hypertrophy
I
Benign prostatic hyperplasia of detrusor
I
Diverliculum
Pathology of bladder
From about the age of 40 years, the prostate undergoes
Trabeculation
enlargement as the result of hyperplasia of periurethral
tissue, which forms adenomas in the transitional zone of the
prostate. Normal prostatic tissue is compressed to form a
surrounding shell or capsule. There is considerable variation Obstruction
in the growth rates of the adenomas and in the proportions of urethra
of stromal and epithelial tissue. A prostate that has been
Lengthening of
infected previously or has a preponderance of stromal tissue
prostatic urethra
is firm and fibrous on rectal examination. Adenomas with
an epithelial preponderance can glorv to form large discrete
414 masses weighing more than 100g, ancl have a characteristic Fig.23.19 Late sequelae of prostatic obstruction.
 Uroiog cal surgery

a.\'peI- infection, coid weather, anticholinergic drugs or excessive FrL)stclte is the principal problem. Alpha-blockers can relax
::ct the alcohol intake can cause sufficient congestion of the blacl- the smooth muscle of the bladder neck and prostatic capsule,
letru- der neck to provoke acute or acute-on-chronic retention. If alld are useful in small prostates; Scx-reductase inhibi-
:.a.1t-ler the patient has a bladder stone, he may have obstructive tors block the intraprostatic conversion of testosterone to
::ticula symptoms during micturition, and there may also be blat-l- rlihvclrotestosterone, resulting in shrinking of the prostate,
:e quite der pain at the end of micturition. Examination reveals little anll are useful in large glands. Prostatectomy (transurethral
e:ticula except rubbery, symmetrical and smooth prostatic enlarge- or open) is reserved for medical failures.
::ations ment, with a median groove between the two lateral'lobes'.
:1 pro- Asymmetry or a hard consistency raises the suspicion of Acute retention
-hronic maiignancy. In a patient with acute painful retention of This condition usually requires emergency admission to
:ration urine, the size of the prostate is more difficult to determine. hospital. If there is a history of bladder outflow obstruction,
erceed In patients with chronic retention, the painless, enlarged conservative measures aimed at encouraging micturition
ililata- bladder rises out of the pelvis, almost to the umbilicus. The (sedation, a warm bath) only delay the inevitable require-
svstem overlying area will be dull on percussion. In addition, the ment for catheterization. A self-retaining Foley catheter
. a renal patient with chronic retention may be ill from obstructive (size 16Fr) is passed using strict asepsis and connected to a
uraemia. closed drainage system. If it is not possible to pass a urethral
catheter, the bladder is entered directly by puncture with
lnvestigations a trocar/cannula (suprapubic cystostomy). A specimen of
urine is cultured and, if there is microbiological evidence of
:am are A good history and exarnination are paramount. Further
an infection, antibiotics are given. If ihe history of urinary
er neck mandatory assessment includes blood for renal function,
symptoms is short, the catheter can be removed after
r (slow haemoglobin and electrolytes, urine culture and PSA. 12 hours (trial zoitltout cntheter), Iollowing which normal
:.stabil- Prostatic cancer can occur with normal PSA values P-ang/
voiding may occur. This is more likely if the patient is given
:he lat- m1) while BPH can cause elevated values, so careful inter-
o-blockers (EBM 23.3). If retention recurs, then definitive
3.tomy. pretation is required (Table 23.3). If digital rectal examina- treatment with TURP is performed.
believ- tion raises suspicion, needle biopsy is indicated. Ultrasound
:eas the
-almost
:\'PIO8-
can detect bladder diverticula, intravesical stones and mea-
sure residual urine volume. A urine flow rate will quan-
tify a reduction in urinary stream. A symptom score sheet e au l;iff l?il',ffi ,.l.nXlff fl[ffi f in
n
I
'er time will quantify the degree of inconvenience and bother. fi 'rockerc
:luc1ing In some patients, especially the elderly, neurological or 'Alfuzosin 1 mg/day increases the likelihood of successful
0

- rinary pharmacological causes for the changes in micturition must trial without catheter (TWIC) in men with a first episode of
be considered. A pressure-flow urodynamic assessment spontaneous urinary retention.'
may be necessary.
[4cNeill SA, et al. Urology 2005; 65(1):83-90.

Management
Patients can be divided into three clinical groups, each
Chronic retention
requiring a different approach to management.
It is essential to determine whether the patient has any com-
Symptomatic only plications of obstruction, especially renal damage. Although
The patient's assessment of the severity of symptoms is the upper urinary tracts may be dilated, renal function
a rosts is not necessarily impaired. If the patient is well, with no
influenced by his age, the social inconvenience caused,
and the frequency and progression of symptoms. A young haematological or biochemical disturbance, there is no indi-
man may be greatly inconvenienced by symptoms that are cation for preliminary bladder drainage and prostatectomy
quite acceptable to one who is elderly. If the exact role of may be planned in the usual way. If the patient is uraemic,
the prostate in causing symptoms is difficult to determine, his general fitness for operation must be assessed. Uraemia
urodynamic studies may be helpful, especially if the symp- alone is not a contraindication to surgery, but hyperkalae-
toms appear to be irritative rather than obstructive. Initial mia, dehydration or other evidence of fluid and electrolyte
management should be medical once prostate carcinoma disturbance must be corrected. The bladder is catheterized
and renal failure are excluded and it is established that the and prostatectomy is carried out as soon as the patient is
fit. Relief of chronic obstruction is almost always followed
by a diuresis, due partly to an osmotic (urea) diuresis and
partly to renal tubular changes resulting from back pres-
sure. Accurate intake/output fluid charts in addition to
ry Table 23.3 tactors affecting the levelof po6tab- daily weights can detect these losses. The blood pressure,
specific antigen (PSA)
both lying and standing, should be monitored and intrave-
nous fluid replacement may be necessary. Medical therapy
Causes of increase in PSA
:' . lncrease in age is contraindicated in patients who present with renal failure
. Acute retention of urine secondary to BPH; these patients should be managed either
:on . Urethral catheterization bv long-term catheter or TURP.
o Transurethral resection of the prostate (I-URP)
. Prostatitis Open prostatectomy
. Prostate cancer Olren procedures are now reserved for verv large
)T
. Large benign prostatic hyperplasia ar-lenomas. Apart from the length of hospitalization
rg of
. Prostatic biopsy (,-10 clavs) and the presence of an abdominal wound,
enucleation of smaller adenomas may damage the external
,'ethra Cause of decrease in PSA
. Patient taking a s-cr reductase inhibitor (finasteride,
sphirlcter and cause incontinence. This is a particular
dutasteride) f.rolrler-n n,ith more fibrous glands and those that contain
.1 iLrcus of cancer. 415
 SURGICAL SPECIALTIES
Closed (endoscopic) prostatectomy
During transurethral resection of the prostate (TURP), the
prostate is removed piecemeal by electroresection using a
resectoscope. The advantages are patient accePtance, short
hospitalization (2-3 days) and the precision of removal of
the obstructing tissue. However, serious damage can be
infticted on the prostatic sphincter mechanism by inexpert
use of the resectoscope. Prolonged resection can result in
excessive absorption of irrigating fluid and electrolyte
imbalance (TURP syndrome). Recent alternatives using
minimally invasive techniques to TURP include transure-
thral radiofrequency needle ablation (TUNA), transure-
thral microwave thermotherapy (TUMT), and transrectal
high intensity focused ultrasound (HIFU). The focused
energy within the prostate causes coagulative necrosis
and subsequent sloughing of prostatic tissue' However,
improvement in symptoms is only modest and no long-
term outcome data are available. More favourable results
are seen with laser prostatectomy but again no long-term
follow-up data is available. The different types of laser
prostatectomy are: holmium only laser ablation of the
prostate (HoLAP), holmium laser resection of the prostate
(HoLRP), and holmium laser enucleation of the prostate
(HoLEP).
Retrograde ejaculation is a common sequel to any oper-
ative procedure on the prostate and all Patients should
be advised preoperatively of this effect. Any associ-
ated bladder stone may be crushed with a lithotriptor or
removed by suprapubic lithotomy. After prostatectomy,
the bladder must be allowed to drain freely via a ure-
thral catheter while the prostatic bed heals and bleeding
stops. After TURP, the catheter is normally removed on
the second postoperative day and after an oPen proce-
dure, the fifth postoperative day. The main postoperative
lnazard is bleeding. In an open procedure, blood vessels
at the bladder neck are sutured but bleeding within the
capsule is less easy to control. With TURP, coagulation of
the blood vessels is more precise but not always complete.
If postoperative bleeding is excessive, clot may lead to
obstruction (clot retention). This hazard can be minimized
by continuous irrigation through a three-way urethral
catheter. The results of all forms of prostatectomy con-
tinue to improve, but TURP has the lowest morbidity and
mortality (< 1%) and requires a shorter hospital stay (50%
less) than other procedures.
Penoscrotal iunction
(pressure necrosis from
catheter or gonococcal urethritis)
Meatal stricture
(trauma f rom instrumentation)
416 Fig.23.20 Common sites and causes ol urethral stricture.
(
Bladder neck obstruction
T
Occasionally, the obstruction to the outflow kact aPPears to u
be at the bladder neck and the prostate is often quite small. n
The cause may be an infective condition such as prostatitis e
or schistosomiasis, or a neurological disorder such as diabe- p
tes or a prolapsed intervertebral disc. Endoscopic incision
or excision of the bladder neck is preferable to long-term
drug treatment, but surgery is relatively contraindicated if Ir
the risk of retrograde ejaculation and hence infertility is of L
concern to the patient. fi
D
(!
Urethral obstruction a.
ir
Pathology a:
i..
Obstruction of the uretfua may be congenital, or due to a
strictureormalignancy (Fig. 23.20). Foreignbodies,including
urinary stones, may also be responsible. The complications n
include inJection with periuretfual abscess, fistulation and \
stone formation. Congenital valves in the posterior urethra
occur only in boys. They lie at the level of the verumontanum \'l
and may cause Bross obstructive changes in the bladder r€
and upper urinary tracts at birth. Increasingly, this diag- (:
nosis is being established during pregnancy by ultrasound r€
examination. If the diagnosis is established after birth, it is ul
conJirmed by micturating cystourethrogaPhy. Treatment
consists of endoscopic incision of the valves. Urethral diver- r€
ticulum is a rare cause of obskuction. More commonly, it is
secondary to obstruction and inJection in women. Urethral
trauma or infection may result in a stricture, the severity of
which is related to both the site and the extent of the insult.
A posterior urethral skicture following major trauma may
be surrounded by dense fibrous tissue, whereas healthy tis-
sues may surround a stricture of the bulb of the urethra. The (
former requires major reconstructive surgery but urethral
dilatation or incision can readily manage the latter. Rough
inexpert use of any instrument (including a catheter) in the
urethra can cause stricture formation. The principal organ-
ism responsible for inflammatory scarring and stricture of
the urethra is Neisseria gonorrlneae. Long-term use of a self-
retaining catheter, although not necessarily associated with
infection, can also cause an inflammatory reaction in the
urethra.
Membranous urethra
(following rupture of urethra) s
c
 Uro ogicai surger\i
'ce rleceptive
Glinical features and the exact character of the urinary abnor-
m.rlitr r.nust be determined so that structural causes car-l
The diagnosis should be considered if there is a historr of
l.e from neurological ones. Details of drug treat-
':a.irs to urethral infection, instrumentation or trauma. The erteinal 'el.aratetl
lrent are notecl since diuretics and drugs with anticholin-
:: >Il1all. meatus must always be examined and, if the foreskin is l.res-
ergic sirle-effects may tip the balance when there is alreatlr'
: -->:atitis ent, it should be retracted for full inspection. The urethra is
c-h'sfunction. Urine is tested for glycosuria and infection. Iir
:: :iaLre- palpated. It is still possible for a patient to pass urir-re, albeit
.-rr-Llition to intravenous urography, there is now a range of
.:.:ision with difficulty, in the presence of a urethral stone. more specific methods for assessing micturition, but not all
. i-term are required for a diagnosis. They include radiology (cvs-
::::.tet1 if lnvestigations tourethrography), urodynamic studies (uroflowmetry, cys-
-::r'is of Urinary flow rate wiil help differentiate urethral strictures tometrography and urethral pressure measurement) and
from bladder neck and prostatic obstruction, the forrner direct inspection (cystourethroscopy and pelvic examination
giving a uniformly 1ow and prolonged (boxJike) pattern under anaesthesia). A fu1l history and physical examination,
(see Fig. 23.5). Post-micturition ultrasound may exclude with cystourethroscopy and bimanuai examination, remain
an increased residual volume. An ascending and descend- the basic initial investigation of structural disorders.
ing urethrogram will adequately demonstrate the urethral
anatomy. The final investigation to assess a urethral lesion Structural causes of incontinence
rue to is cystourethroscopy.
a in males
:.--iurling
'.:cations Management Postprostatectomy
:--on alld Many simple strictures are easily treated by repeated dila- Disordered controi of micturition occurs in 3-5% of patients
: urethra tation with metal bougies, or may be incised under direct after prostatectomy. In this operation, any inadvertent dam-
t:1tanum vision using an urethrotome. Most short strictures in the age to the external sphincter can lead to difficulties with con-
-rlaclder tinence. Stress incontinence may occur, but as the damage
region of the bulb respond well, but recurrence is common
:-rs diag- (50%) and operative reconstruction (urethroplasty) may be to the sphincter is usually incomplete, it usuatly responds
to physiotherapy. If not, insertion of an artificial urinary
:asound
::th, it is
tSatrllent
required. Short strictures can be excised and the healthy
urethra re-anastomosed. Longer strictures can be patched
with full-thickness skin flaps or buccal mucosal grafts, to
sphincter can be considered.

Chronic outflow obstruction

Z
I
::.1 diver- restore normal calibre.
Changes within the bladder (detrusor hypertrophy) due to
--rlv, it is
chronic obstruction commonly lead to secondary urgency
- rethral and detrusor overactivity. Relief of obstruction alone is usu-
-'. eritv of
:.einsult. ally sufficient to correct the associated urgency and urge
incontinence, but in about 10% of cases the instability is pri-
-r1a rnay
:ltl-n'tis- mary and antimuscarinics may be necessary. Chrouic reten-
:1ra. The
tion may also lead to ov6rflolr. or dribbling incontinence. It
'-rrethral
Overview must be emphasized that continence requires normal corti-
ca1 control, and in an elderly patient this may be impaired.
:. Rough Incontinence is defined as the involuntary leakage of urine. Possible abnormalities of both structure and innervation
=:r in the It may be due to problems in storage, resulting in urge and need to be considered in these patients.
-:l organ- stress incontinence or continual incontinence with fistulae,
::cture of or to problems in emptying, resulting in chronic retention Carcinoma of the prostate
..i a self- with overflow incontinence. In stress incontinence, leak- Tumour may involve the external sphincter, prevent-
r;et-l rvith age occurs because passive bladder pressure exceeds nor- ing it from closing. Repeated transurethral resections for
:r in the mal urethral pressure. This may be because of poor pelvic recurring obstruction may convert the posterior urethra
floor support, because of a weak urethral sphincter or an into a rigid tube so that dribbling incontinence occurs. An
element of both. In urge incontinence, leakage usually indwelling catheter or condom incontinence appliance may
occurs because detrusor overactivity produces an increase be necessary.
in bladder pressure that overcomes the urethral sphincter.
A hypersensitive bladder (sensory urgency) resulting from Postmicturition dribble incontinence
urinary tract infection (UTI) or bladder stone may also drive This is very common, even in relatively young men, and
urgency in the absence of overactive bladder contractions. is caused by a small amount of urine becoming trapped
Incontinence in these circumstances is less common. Stress in the'U-bend' of the bulbar urethra. This then leaks out
incontinence and urge incontinence may coexist (mixed passively when the patient moves. The condition is more
incontinence). All of the above terms, with the exception of pronounced if associated with a urethral diverticulum or
a fistula, are descriptive only and do not accurately diag- urethral stricture.
nose the underlying pathophysiology, which can only be
determined by urodynamic testing.
Chronic illness and debility
Especially in the elderly, incontinence may arise from poor
tone in the periurethral striated muscle of the pelvic floor
3:h ra) Structural disorders ancl from difficulty in getting to the toilet. This may be
rrorsened by loss of cortical inhibition of micturition.
Clinical assessment
Abnormalities of function of the iower urinarv tract are
Structural causes of incontinence
notoriously difficult to assess because there is frequenth' in females
dual underlying pathology. Incontinence in an elclerh' r.nau Incorrtiuence is more prevalent than generally suspected;
may be due to ceiebral coitical degeneration, but cor:i.l elst .rl.pro\imately 1,4% of all women have been incontinent
be due to chronic outflow tract obstruction resulting ir..rl .1t sLrrne time, half of them within the last 2 months. This
prostatic hyperplasia. The history is important but nrar' :::r-rre rises rapidly in olcler patients, and reaches 50-70% 4l I
J SURGICAL SPECIALTIES
ts in geriatric units. Only a proportion of younger women
seek advice, either because of embarrassment or because of
stoical acceptance of some incontinence as being normal.
Childbirth and operations
Multiparous women commonly lose some of the tone in the
pelvic floor muscles with each pregnancy. Symptoms may
range from occasional stress incontinence to almost contin-
ual dribbling incontinence. Examination shows weakening
of the pelvic floor muscles and anterior vaginal wall (cys-
tocoele). It is important to distinguish stress incontinence
from urge incontinence. The former responds well to pelvic
floor exercises and to surgical procedures designed to sup-
port the bladder neck, but the latter should be treated by
bladder retraining and drug theraPy. Stress incontinence is
characterized by an involuntary loss of urine during cough-
ing, laughing, sneezing or any other activity that suddenly
raises the intra-abdominal pressure. A cough, however, may
stimulate involuntary detrusor contractions (cough-induced
detrusor instability), which causes urge incontinence. This
differential diagnosis can be made only by urodynamic
assessment. In parts of the world where obstetric services
are poor, prolonged labour may lead to a vesicovaginal fis-
tula, which presents as continuous dribbling incontinence.
The association with delivery is usually clear, but a small
fistula may be missed. Investigation of dribbling inconti-
nence must distinguish between urethral damage and a
fistula. Treatment consists of closing the fistula through a
vaginal or suprapubic approach.
Cystitis
Cystitis is common in women and, in addition to causing
frequency, urgency and dysuria, sometimes causes sensory
urge incontinence. Treatment of both the inJection and the
bladder spasm is required. Interstitial cystitis (pain{ul blad-
der syndrome) is a chronic inflammatory condition that, in
addition to causing frequency and dysuria, may also cause
urgency and urge incontinence. Treatment is often uusatis-
factory. Hydrostatic dilatation may be effective.
Ectopic ureter
Dribbling incontinence in a child should raise the suspicion
of an ectopic ureter, in which the lower of the two ureters
opens outside the control of the urethral mechanism- The
abnormal ureter must be relocated in the bladder.
Cervical cancer
Carcinoma of the cervix or its treatment by radiotherapy
may cause vesicovaginal fistula and incontinence.
Neurogenic disorders
Clinical assessment
A full history, including an interview with relatives, is
required. Examination must include assessment of the plan-
tar reflexes and the sensation and tone of the anal canal.
Glycosuria and urinary infection should be excluded.
Urodynamic, radiological and electromyographic studies
may all be required.
Aetiology of abnormal micturition
lmpaired cortical control
Diseases affecting the frontal lobe can alter the pattern of
micturition by increasing or decreasing its frequency, or by
affecting the social awareness of incontinence. There may
also be failure toinhibit initiation of micturition. The para-
central lobule controls the activitv of skeletal muscle, so that
,1
+ lo6 lesions in this area may cause sustained peivic and perineal
muscular contractior-r. It must be rernembered that a disor-
der of micturition may be accentuated by, or may even be
due to, the physical inability to prepare for micturiiion such
as poor mobility. \
lt
Emotional state I
This may affect the postPonement of micturitiory giving rise to
'giggld incontinence and possibly to enuresis in some patients. I
Incontinence with epilepsy is aiso due to a loss of inhibitory F
control. Excessive sensory stimuli, as with the pain of cystoure- tl
thfitis in women, may cause'sensory urge incontinence'. 11
a
Drugs n
Drugs, including alcohol, may alter cortical control of mic- p
turition. Sedatives can affect the postponement phase and b
precipitate incontinence, especially at night. The intoxicated tI
patient may lack the rnental alertness to maintain conti- I1
nence, or may continually suppress the desire to void, lead- S]
ing to prostatic congestion and retention.
Ll
Damage to the spinal cord ir
Two aspects of disease or injury to the spir-ral cord influence li
disordered micturition: narnely, the level of the disease and ir
the completeness of the damage. C'
Injury at or below the sacral outflow (52,3, 4) may be due u
to a fracture of the spine at the level of T12 and L1 which s1
damages the conus medullaris, a central prolapsed inter- (r
vertebral disc leading to cauda equina injury, or to spinal SI
stenosis. The bladder distends without sensation, the exter-
P
nal sphincter is weak and little detrusor contraction is seen r(
upon urodynamic assessment. The patient develops reten-
tion ra,ith overflow, but emptying is possible with abdomi-
I\
nal straining or hand pressure.
Injury between the sacral segment and the pontine mictu- T
rition centres (upper motor neuron lesions) may be due to ir
fractures of the spine; tumours that compress the cord; surgi- P
cal removal of such a tumour; and diseases of the cord itself, tl
such as multiple sclerosis, transverse myelitis and cervical C(
cord stenosis. If these central connections are disrupted, the b:
patient develops a reflex bladder with impaired or absent ir
a!
cortical control; that is, the bladder loses the coordination
le
imposed by the pontine micturition centre. The detrusor
becomes overactive and attempted voiding results in detru-
sor contraction occurring synchronously with that of the
external sphincter (detrusor-sphincter dyssynergia). The net (
result is poor bladder emptying and the development of a
thick, trabeculated bladder wal1. The resultant high-pressure
bladder will, over time, lead to renal impairment. Usually
the central connections are not completely disrupted and
there may be some sensation and some cortical inhibition.
Damage to pelvic nerves may occur in the course of sur-
gery, especially when dissection involves the side walls of
the pelvis, as in radical dissection of the rectum or the uterus.
Similarly, aneurysm surgery may disrupt neural pathways
in the pelvis. Diseases affecting the autonomic system, prin-
cipally diabetes mellitus, also affect the control of micturi-
tion. With the loss of sensation and contraction, the bladder
becomes atonic, prone to the complication of stasis infec-
tion. The external sphincter remains closed by uninhibited
tonic contractions, but the internal sphincter is partly open
as it, to some extent, depends on detrusor activity.
Primary failure of the detrusor has been described, but it
is usually secondary to chronic overdistension. Atonic myo-
genic bladder is caused by prolonged outlet obstruction and
is found in the late stages of bladder decompensation. The
most common cause is silent prostatic obstruction, where
progressive loss of the desire to void results in overflow
incontinence. In women, conscious Postponement can lead
to a large atonic bladder.
 .: .1isor-
Uro ogica sr-rrrr:
t
.r en Lre Principles of management
I --:.r sLlcl1
More than one mechanism may account for disorclerecl
micturition and urodynamic assessment is mandatorv in ali
Anatomy
patients with a suspected or proven neuropathic bladcler..
-: h'r the male, these comprise the penis, testicles and scrotum;
rise to
in the fernale, the mons pubis, labia majora, labia rninora
:alients. Neurologically intact patients and the clitoris (Fig. 23.21).
'j-ritritory
Patients with congenital defects or fistulae should have The penis consists of three cylinders of erectile tissue. The
:'. stoure-
these repaired surgically if possible. If the fistula is malig- ventral corpus spongiosum is expanded proximally as the
nant or the surrounding tissues are poor because of radi- bulb and distally as the glans penis, and transmits the ure-
ation, urinary diversion is preferable. Stress incontinence thra. Two dorsolateral corpora cavernosa attach to each side
in both males and females should be treated initially with of the inferior pubic arch as the crura. They form the body of
. of mic-
pelvic floor exercises. If it persists in maIes, it is best treated the penis and become embedded in the glans.
'.ase and
by the insertion of an artificial urinary sphincter. In females, The penile skin is hairless, free of fat, and extends over
-.ricated the urethra and bladder neck should be returned to their the glans as the prepuce or foreskin. Blood is supplied from
.r conti- natural positions and supported by means of colposuspen- the internal pudendal arteries. The scrotum is a thin rugose
:1, Iead-
sion or a pubovaginal sling. The injection of bulking agents pouch of skin containing the two testicles. Each testicle is
at the bladder neck can improve continence, but remains contained within a tough capsule (tunica albuginea) and
under evaluation. Urge incontinence should be treated has the epidiclymis attached to it posteriorly. This highly
initially by bladder retraining, supplemented by anticho- coiled tubular structure arises from the rete testis, where
:J'luence
linergic drugs. If this fails, good results can be obtained by some 20 sma1l tubules enter it. This head of epididymis is
and
=.rSe intravesical injection of botulinum toxin type A via flexible considerably larger than the lower tai1, from which the vas
cystoscopy. Alternatives are insertion of a sacral nerve stim- deferens arises to traverse the spermatic cord and finally to
'. te due
ulator device, a detrusor myectomy which typically involves open into the prostatic urethra as the ejaculatory duct. The
-- n'hich stripping off a substantial proportion of the detrusor muscle testicle and epididymis are invaginated into the tunica vagi-
=l inter-
:.. spinal
(myectomy) or splitting the bladder in half and suturing a
strip of small bowel to augment the bladder (clarn ileocysto-
nalis, which lies anteriorly, so providing a potential space
where a hydrocoele may form. The testicular arteries sup-
Z
I
:'.e exter-
plasty). Patients with atonic bladders are best managed by ply the testes. Venous blood drains along the spermatic cord
r. is seen
regular intermittent self-catheterizaiion (lSC).
ts reten-
:L.clomi-
Neuropathic patients
te mictu- These patients are prone to urinary infection and renal
E
Mons Pubis
e clue to impairment, and preservation of renal function takes Prepuce -_---==--1;-
-.i; surgi- priority. The patient's overall condition is important and of clitoris
':i1 itself, those that are poorly motivated or immobile r.r,ith poor Labium majus Clitoris

-ervical cognition and hand function are best managed bv suprapu- Labium minus External
:te11, the bic catheterization or urinary diversion. Highly motivated urinary
': absent intelligent patients should be treated in much the same way Fourchette meatus
'lination as the neurologically intact, although the results are often Anus ___-______* Vagina
-t etrusor less good.
:: t'letru-
:: of the -.=--,---,,-..---
The net
:'.ent
':ressure
of a $ tu**o*rBox2s.b tr
Corpus
Mictutition
L sually cavernosum Urethra
::et-l and
. Micturition requires parasympathetic innervation (S2-S4)
Corpus
of the detrusor, sympathetic innervation [1 0-12) of
Penile bulb
:ition. spongiosum
:a lrf sur- the bladder neck and proximal urethra, and somatic Left crus of
'.r innervation (S2-S4) of the bladder, pelvic floor and urethra Glans penis penis
alls of
.a uterus. o Structural causes of disordered micturition in the male Head of
':tl-nvays include prostatic enlargement, prostatectomy (dribble, epididymis
=r, prin- stress and urge incontinence) and chronic illness/debility Vas deferens
nicturi- . Structural causes of disordered micturition in the female
Prepuce Efferent
, :ladder include childbirth, surgery, radiotherapy and cystitis
.:. infec- (infection, chronic interstitial cystitis and urethral syndrome) External ductules
::Lhibited . Neurogenic causes of disordered micturition are: u rinary Tail ol
::iv open o impaired conical control meatus epididymis
o alcohol abuse and drugs
=1, but it o spinal cord damage (aVbelowT12-11 -flaccid bladder
:.ic r-nvo- C Corpus cavernosum
with ovedlow; above T12-11 - overactive bladder with
::ron and incoordination of urinary sphincter, which results in poor Deep fascia of penis
::..n. The bladder emptying)
(Buck's fascia)
:.. rr'here o pelvic nerve damage (surgery, diabetic autonomic Urethra
Corpus spongiosum
-'r'ert-low neuropathy)
-f,r1 lead o atonic myogenic bladder (prolonged outlet obstructi0n). 15,23.21 Anatomy of the external genitalia. I Femate. @ Mate
419
C "..s-section through the penis,
F
i:rB
SURGICAL SPECIALTIES
as the pampiniform plexus. The scrotum drains lymph to
the inguinal lyrnph nodes, and the contents of the scrotum
drain along the spermatic cord to nodes in the pelvis and
abdomen.
In the female, the mons pubis is the fatty elevation over
the pubis from which the labia run backvvards, enclosing
between them the vestibule into which open the vagina and
urethra. The clitoris lies above the urethral opening and is a
smaller replica of the penis, with the same erectile tissues.
Physiology
Parasympathetic stimulation leads to erection through
the release of nitric oxide, with resultant vasodilatation
of the arterioles, increased penile blood flow and passive
closure of the venules. After sufficient stimulation, sperm
from the epididymis and seminal fluid from the seminal
vesicles are emptied into the prostatic urethra. Sympathetic
stimulation is responsible for this emission, and also closes
the bladder neck to prevent leakage of semen into the blad-
der. Ejaculation proper is due to rhythmic contraction of the
bulbospongiosus muscles expelling the semen out through
the urethra.
Circumcision
The foreskin is normally non-retractile for the first few
months of life. By the end of the first year, half will retract,
but it may be 3-4 years before all do so. Provided the par-
ents are reassured, there is no reason, apart from religious
grounds, to remove the foreskin within the first few years
of life. In some children, the foreskin remains non-retractile
and has to be treated by division of preputial adhesions or
by circumcision. Otherwise, secretions collect under the
foreskin, leading to infection (balanitis) and narrowing of
the orifice (phimosis).
Severe phimosis may obstruct urinary flow and if a
poorly retracting foreskin remains retracted, it can act as a
tight band and cause engorgement and oedema of the glans
(paraphimosis). This demands urgent treatment. It may
be possible to compress the glans and draw the foreskin
forwards, but if this fails, the tight band must be incised
under general anaesthesia. Later, elective circumcision is
advocated.
Congenital abnormalities of the penis
Hypospadias
Failure of the embryonic folds to fuse results in abnor-
ma1 placing of the external urinary meatus on the ventral
surface of the penis. The opening may be coronal, penile,
scrotal or even perineal. The corpus spongiosum rnay be
scarred and fibrosed, leading to a ventral curvature or
chordee of the penis. The aim of treatment is to correct the
chordee by excising the fibrosis, and then to construct a
new urethral opening in the normal position on the glans.
This procedure should be ideally completed before the boy
goes to school.
Epispadias
In this condition the external urinary meatus opens on the
dorsal surface of the penis. The extent of the malforma-
tion varies from an isolated penile abnolmality to gross
malformation of the bladder and urethra. The mucosa
of the bladder and the ureteric orifices rnay be exposed
42U and form the infraumbilical part of the abdominai wall
(exstrophy). The urethra then lies opened out like a gutter.
Other associated abnormalities include separation of the
symphysis pubis and rectal prolapse. Reconstruction of
these deformities is not always successful, and urinary
incontinence may remain a major problem and require
urinary diversion.
Disorders of erection (impotence)
Impotence may be psychogenic, organic or drug-induced.
Psychogenic problems, the most common cause, can usu-
ally be established from a careful history that includes
details of sexual habits. Organic impotence is associated
with diabetes mellitus, neurogenic disorders, major pelvic
injury or operations, vascular disease of the pelvic vessels
(Leriche's syndrome), priapism and Peyronie's disease.
Most of these conditions constitute irreversible irnpotence.
Drug-induced impotence occurs with hormonal manipula-
tion for prostatic cancer; some antihypertensive drugs may
cause loss of erection or inability to ejaculate, and barbitu-
rates, benzodiazepines, corticosteroids, phenothiazines and
spironolactone may affect libido. Medicai treatment is by
oral sildenafil (Viagra), intracavernosal (self)-injection of
papaverine, or prostaglandin E. Vacuum suction devices F
or a prosthesis implanted into the corpora cavernosa are
effective alternatives.
Ll
Priapism p
Si
This is a painful maintained erection unassociated with a
sexual desire. It is associated wiih intracavernosal self- ll
injection for irnpotence (the most common cause), leukae- tl
mia, disorders of coagulation, renal dialysis and sickle-ce11 tt
trait, and is believed to be due to venous sludging in the
corpora cavernosa. (The corpus spongiosum and glans p
are unaffected.) Aspiration and intracavernosal injections tl
of vasoconstrictors (phenylephrine) may be effective, b
especially in self-injection cases. If these fail, the creation of
a venous shunt within 6-12 hours gives satisfactory results,
I
and the patient can achieve normal erections subsequently.
If treatment is delayed or incomplete, the erectile tissue is
II
damaged and the patient r,t'ill be impotent.
ir
\\
Peyronie's disease r(
(T
This is the occurrence of a hard fibrous plaque (or plaques)
CI
in the wall of a corpus cavernosum, causing curvature of the o
penis. The cause is obscure but is possibly related to trauma, al
leading to the formation of hard scar tissue. In addition to the r(
defonnity, the patient complains of pain during intercourse. tl
Various treatments, including cortisone injections, vitamins al
and radiotherapy, have met with little success. Excision of
the plaque and replacement by a dermal patch graft, or exci-
I
sion of a wedge of tissue on the convex (opposite) border of
the penis, may be effective.
F
Carcinoma of the penis N
al
il
This uncommon tumour has a prevalence of 1.5 cases per
100 000 and is generally attributed to poor hygiene associ- ir
ated with a non-retractile foreskin (Fig. 23.22). It is very rare a
in circumcised men and almost always occurs in the elderly. l-Ir
The cancer may be a papillary or an ulcerating squamous tc
cell carcinoma. Local spread occurs early and the tumour ul
may ulcerate and fungate. Lvmphatic spread to inguinal 1.
lymph nodes is comrnor-r; associated infection may also
lead to lyrnphadenopathr'. The p1tisl-ri may present with a
.a -1 gutter.
i;l,,plr. An ectopic testis has developed normallv, but
:r.rn of the
aiter p.rs5ipg through the external inguinal ring its
::ation Of
further descent is impeded. It either remains in the
:i urinary superficial inguinal pouch (common) or is transposecl
-.J require
to ps1ing61, femoral or prepubic sites (rare).

Torsion of the testis

:-rncluced. Torsion of the cord can occur where the visceral layer of the
aan usu- tunica vaginalis completely covers the testis so that it lies
: susperrded within the parietal layer. The patient, usually a
lncludes
ls:ociated teenager, presents with sudden onset of testicular pain and
:;or pelvic swelling. There may be a history of minor trauma, or previ-
ous episodes of pain due to partiai torsion. On examination
:c vessels
. rlisease.
there is a red, swollen hemiscrotum that is usua\ too ten-
:potence. der to palpate. Misdiagnosis of the swelling as epididymo-
:anipula- orchitis, which is rare in teenagers, is a serious error. Torsion
l:ues may of the testis is a surgicai emergency; if the blood supply is
: barbitu- not restored within 12 hours, the testis infarcts and must
zines and then be excised. If at operation the testis is found to be via-
'.ent is by ble, it is sutured to the parietal tunica to prevent recurrence.
'ection of As the underlying abnormality of the tunica is bilateral, ihe
:l rlevices other testis must be fixed at the same time.
Fig. 23.22 Penile carcinoma.
:TIOSa are

Testicular tumours
purulent or blood-stained discharge. Unfortunately, many
patients do not seek help until the lesion is advanced - Pathology
Z
I
some oniy when much of the penis is already destroyed
Tumours of the testes are uncommon, with a prevalence of 5
r:ei-l with and the inguinal Iymph nodes are involved. The diagnosis
cases per 100 000. They most commonly affect men between
..sal self- must be confirmed by biopsy. Circumcision may cure early
20 and 40 years of age. Seminoma and teratoma account for
. leukae- tumours confined to the prepuce. Early tumours confinei 85%; malignant lymphoma, yolk-sac tumours, interstitial
.:ckle-ce11 to the glans may be treated by excision of the glans and skin
cell tumours and Sertoli ce1l/mesenchyme tumours make up
::g in the grafting. Advanced tumours will require pirtial or total the remainder. Seminomas arise from seminiferous tubulei
:.cl glans penile amputation, and often bilateral block clissection of
:njections
and are of relatively iow-grade malignancy. Metastases
the inguinal lymph nodes. Inoperable tumours are treated
occur mainly via the lymphatics and may involve the 1ungs.
eifective, by radiotherapy.
Teratoma (non-seminomatous tumour) arises from priii-
:eation of
l tive germinal cells. It may contain cartilage, bone, muscle,
results,
equently. Inflammation of the penis tat and- a variety of other tissues, and is classified according
to the degree of differentiation. Well-differentiated tumours
iissue is
Inflammation of the glans penis (balanitis) usually also are the least aggressive; at the other extreme, trophoblas-
involves the prepuce (posthitis) and is common in children tic teratoma is highly malignant. Occasionally, teratoma
with poorly retractile foreskins. Circumcision usuallv cures and seminoma occur in the same testis. A history of unde-
recurrent non-specific balanitis. Balanitis xerotica obiiterans scended testis increases the risk of malignancy in the ipsilat-
(BXO) is the local manifestation of lichen sclerosus et atrophi- eral testis. Orchidopexy does not reduce this iisk but it does
rlaques) cus. of the glans and prepuce. It causes typical white scu.ii.,g allow the testis to be moved into a position where it allows
:re of the of the prepuce and glans, and may involve the urethral meatus regular self examination.
r trauma, and distal urethra. Meatal stenosis occurs as a result of recur-
:.rn to the rent infection, trauma or BXO. It may respond to removal of Clinical features
a:aourse. the inflammation @y circumcision) and meatal dilatation; The most common presentation is the incidental discovery
';itarnins alternatively, it may require meatotomy or meatoplasty. of a painless testicular lump. The history is often vague,
.rsion of
however, and symptoms may be attributed to an injury, or
:. or exci-
Undescended testes (cryptorchidism) there may be pain and swelling suggesting inflammation.
rorder of
The patient may have wrongly received treatment for,acute
epididymitis'. Very rarely, patients with teratoma may com-
Retractile testis plain of gynaecomastia. Irrespective of the history, any new
Normally, both testes are in the scrotum by 6 months ol painless testicular lump in a young man must bL regarded
age. However, they may be excessively mobile and reacl- r,r,ith suspicion. A hydrocoele in a young man also demands
::eS PeI ily retract towards the external inguinal ring, even into tl-re investigation, as testicular tumorrrs muy be accompanied by
. associ- inguinal canal, especially when the patient is examined ir-r blood-stained effusion in the tunica vaginalis.
,-er\. rale a cold room. Such retractile testes may easiiy be misdiag-
.ei.1erly. nosed as being incompletely descended. Care must be takerr lnvestigations
:..:amous to examine the baby in a warm room or after a bath. True ,\llsuspicious scrotal lumps should be imaged by ultra-
:umour undescended testes are of two types:
which provides a high degree of accuiacy. As soon
sotu-rc1,
:rguinal 1. Incomplete. Such a testis is arrested in its norrnal as a tumour is suspected, and before orchiectomy, serum
'.av also pathway to the scrotum. Usually this is within the levels of AFP, B-HCG and LDH should be determined. The
.: rr'ith a inguinal canal, more rarely within the abdornen. levels of these'tumour markers' are increased in extensive 4Zl
T
ii
SURGICAL SPECIALTTES

iiB Table
canoel
23.4 Boyal Marsden dassification lorbsticular
a Stage 1 Tumour confined to testis
a Stage 2 Tumour spread only to lymph nodes below diaphragm
a Stage 3 Tumour spread only to lymph nodes above and
below diaphragm
Stage 4 Tumour spread to inguinal lymph nodes or distant
metastases
disease. Accurate staging is based on CT of the lungs, liver
and retroperitoneal area, and an assessment of renal and
pulmonary function (Table 23.4).
Management
Through an inguinal incision the spermatic cord is divided
at the internal ring; only then is the testis retnoved.
Radiotherapy is the treatment of choice for early-stage sem-
inoma, as this tumour is very radiosensitive. The manage-
ment of a teratoma depends on the stage of the disease.
Early disease confined to the testes may be managed with-
out further treatment, provided that there is close surveil-
lance for at least 2 years; tumour progression is treated by
chemotherapy. More advanced cancers are managed ini-
tially by chernotherapy, usually with a combination of bleo-
mycin, etoposide and cisplatin. Retroperitoneal lymph node
dissection is now only performed for residual or recurrent
nodal masses. AFP, B-HCG and LDH each offer a valuable
means of monitoring response to treatment and detecting
recurrent disease. These markers should be monitored in
all patients with testicular tumours for at least 2 years after
they are considered to be tumour-free. CT is used to follow
the response of enlarged lymph nodes to treatment.
Prognosis
The S-year survival rate for patients with seminoma is
90-95%. The more variable prognosis of teratomas depends
on tumour type, stage and volume. With more favourable
tumours the S-year survival rate may be as high as 95%, but
in more advanced cases 60-70% is more usual.
tS trrro*tBoxzs.o
Testicular tumours
Epididymo-orchitis
Acute epididymo-orchitis is usually the appropriate term,
as both testis and epididymides are involved in the acute
inflammatory reaction. The spermatic cord is also often
thickened (funiculitis). A{ter infection has subsided, the
epididymis alone may remain thickened and irregular, so
thatchronic epididymitis maybe diagnosed. Thus a late effect
of tuberculosis is an irregularly hard (craggy) epididymis.
Apparent involvement of the testis aione may be a feature of
viral infections such as mumps orchitis. The usual cause of
epididymo-orchitis is bacterial spread, either from infected
urine or from gonococcal urethritis. The affected side of the
scrotum is swollen, inflamed and very tender. In all cases,
the urine or urethral discharge must be cultured. Sometimes
there is no evidence of a bacterial cause and a viral aetiol-
ogy is then likely. Treatment consists of antibiotics, analge-
sia, bed rest and a scrotal suPPort. The choice of antibiotic
depends on the results of culture and sensitivity determina-
tion of the organism responsible. If there is any doubt about
the diagnosis, the testis should be explored. Abscess forma-
tion is now rare, but if signs of localization or fluctuation
develops, the pus should be drained. Infertility is an impor-
tant late complication of epididymo-orchitis.
Hydrocoele
This is a common condition, especially in older men, in
which fluid collects in the tunica vaginalis, resulting in an
enlarged but painless scrotum. The inconvenience of its size
usually leads the patient to seek advice. The cause of most
hydrocoeles is unknown (idiopathic). The fluid is straw-
coloured and protein-rich. In some patients, a hydrocoele
develops as a reaction to epididymo-orchitis. Rarely, it may
develop with a malignant testis (secondary hydrocoele) and
the fluid may then be blood-stained. On examination of the
scrotum, a normal spermatic cord can be palpated above a
smooth oval swelling. Typically, an idiopathic hydrocoele
transilluminates (Fig. 23.23), b:ut where it is long-standing
this may be difficult to elicit, owing to fibrosis and thicken-
ing of its wa11. It is important aiways to seek this physical
sign and also to examine the neck of the scrotum carefully
to exclude an inguinal hernia as the cause of the swelling. It
may be possible to palpate the testis and conJirm that it is
normal, but this is unusual as it lies behind and is enveloped

ln the UK, there are about 1 000 new cases of testicular

tumour per year and the 20-40-year age group is
predominantly affected
Seminomas and teratomas account for 85% of all
testicular tumours
o Seminomas arise from the seminiferous tubules, are of
relatively low-grade malignancy, spread mainly via the
lymphatic system and are very sensitive to radiotherapy
. Teratomas arise from germinal cells, their differentiation
ref lects their aggressiveness (well-differentiated
tumours being the least aggressive) and they are not
radiosensitive
. Treatment consists of radical orchiectomy (with division of
the spermatic cord at the level of the deep inguinal ring).
Radiotherapy is used if the tumour proves to be a seminoma,
whereas chemotherapy (bleomycin, etoposide and cisplatin)
is used for teratomas that are advanced 0r recurTent
. Seminomas have a S-year survival rate 0f 90-95%,
whereas teratomas have a more varied prognosis
(60-95% S-year survival rate).
422 Fig. 23.23 Hydrocoele demonstrating transilluminati0n.
 Uro ogrca surge'\

by the hydrocoele. If there is any doubt about the cliagno-

sis, then an ulkasound should be performed. Injurv to the
scrotum may result in a sweiling that resembles a hvc-lro-
r telm/ coele but does not transilluminate because the tunica has
i acute filled with blood (haematocoele). Aspiration alone does not
: rrften cure an idiopathic hydrocoele and the tunica soon refills. It
:1, the is possible to obliterate the sac by injecting a sclerosant after
i.ar, so aspiration, but surgical excision and eversion is associated
:e effect with a much lower recurrence rate. If the hydrocoele fluid
:lvmis. becomes infected, incision and drainage of the pus is neces-
::ure of sary. Similarly, a haematocoele may require treatment by
ause of incision and drainage.
:Jected Hydrocoele is a common abnormality in children. It is due
. oi the to failure of closure of the processus vaginalis after descent of
.. cases, the testis. This patent processus vaginalis (PPV) allows fluid
:.eiimes to drain into the scrotum around the testis. Most congenital
- aetiol- hydrocoeles of this sort resolve before the first birthday.
analge- Those that persist require surgical treatment comprising
'.ibiotic ligation of the PPV through a small groin incision.
e:mina-
r: about
Gyst of the epididymis
' forma-
:tuation
Cysts in the epididymis arise from diverticula of the vasa
tmpor-
efferentia. The distinction between a cyst of the epididymis
and a hydrocoele is easy. Epididymal cysts are almost
always multiple and, therefore, nodular on palpation; they
are located above and behind the testis, which is palpably
separate from the cysts, and always transilluminate brightly.
n
I
::ren, in A solitary epididymal cyst may even resemble a testis, so giv-
'.9 in an ing rise to fables of tfuee testes and the term'pawnbroker's
: its size sign'. Sometimes the fluid within an epididyrnal cyst is opal-
of rnost escent and contains sperm (spermatocoele). Usually the fluid
. straw- is clear. It is best to leave these cysts alone unless increas-
::ocoeie ing size warrants excision. Careful dissection is needed to Fig.23.24 Varicocoele. I Before treatment. E After radiologlcal coil
. it may remove the cyst completely. Often several other little cysts embolization,
e1e) and are present which, if not removed, will eventually increase
'n of the in size and produce a so-called recurrence. If all the cysts
above a are removed, the pathway for sperm will almost certainly be
damaged. Bilateral operations can result in sterility.
left side, possibly because the right-angled drainage of the
irocoele
:ianding left testicular vein into the renal vein renders it more liable
to stasis. In some men, varicocoele is associated with infertil-
:ricken-
Varicocoele ity. A dragging sensation in the scrotum may cause concern.
:hvsical
Treatment is by ligation of the spermatic vein, which may
:arefully
The veins of the pampiniform plexus are dilated and tortu- be done surgically (laparoscopically) at the internal ingui-
elling. It
ous, producing a swelling in the line of the spermatic cord nal ring. Alternatively, the feeding veins can be obliterated
:rat it is
that resembles a'bag of worms'. It is more common on the radiologically by means of coil embolization (Fig. 23.24).
.r-eloped

423