UROLOGY/URINARY SYSTEM

Oleh : Ahmad Fakhrozi Helmi

Pembimbing : dr. Alvarino, Sp. B, Sp. U

EMBRYOLOGY
The kidneys and gonads are derived from
a mesodermal structure (Mullerian ridge).
The Mullerian and mesonephric (Wolffian)
ducts differentiate into portions of the
internal genitalia and the urinary tract.

 The ureteral bud emanates from the distal

Wolffian duct and migrates rostrally to
impact the metanephros.
Metanephros divide to form the structures
of the renal pelvis, infundibula, and
calyces
the Wolffian duct
Involutes (female) may persist as the Gartner
duct cysts.
Persists (Male) becomes the vas deferens.

 The Mullerian ducts

Persist (female) fallopian tubes, uterus,
and proximal third of the vagina.
Regres (Male) the prostatic utricle and
appendix testis.

 The bladder and proximal urethra are

derived from the urogenital sinus, of
endodermal origin.
Divided by the transverse rectal folds into
the anorectal canal and the anterior
urogenital sinus.
The urogenital sinus then divides
Proximally into the bladder.
Caudally into the posterior urethra
(male),entire urethra (female)

 The anterior urethra is derived from

mesodermal structures associated with
the genital tubercle.
Develops into the corpus spongiosum and
urethral epithelium anterior (distal)
urethra
Gonadal ridge differentiates into the testis

RENAL PHYSIOLOGY AND ANATOMY

FOR SURGEONS
The kidney's function
Regulation of fluid volume.
Insulin degradation,
Erythropoietin production,
Vitamin D synthesis
Activation, secretion of organic Ions, ammonia
genesis, and bicarbonate reabsorption.

 The human kidney is composed of

approximately I million functional units
termed nephrons.
The nephron consists of
Corpuscle (glomerulus),
Proximal convoluted tubule,
Thin loop of Henle,
Distal tubule, and
collecting duct

 The kidneys receive approximately 20 %

of cardiac output
The renovascular network consists of a
single renal artery and vein.
In the renal hilum, the artery divides into
an anterior division and a posterior
division each with five branches.

NEPHROLOGY FOR SURGEONS

Nephrosis significant proteinuria and scant,
cellular sediment (Nephrotic syndrome> 3.5 g/d of
proteinuria, systemic edema, hypoalbuminemia, and
hyperlipidemia)
Nephritis proteinuria, edema, hematuria, and
hypertension (acute poststreptococcal
glomerulonephritis, mesangioproliferative
glomerulonephritis, membranoproliferative
glomerulonephritis)
Tubulointerstitial disease affect solute, water,
acid-base, and electrolyte abnormalities (Fanconi
syndrome, lithium nephrotoxicity, and cyclosporine
nephrotoxicity.

 Acute tubular necrosis setting of ischemia

(vasculitis, atheroembolic disease).
Renal cystic disease genetic or acquired
( Nephronophthisis, medullary sponge kidney
disease, polycystic kidney disease
Hereditary renal disease heterogeneous
group of disorders ( Alport syndrome :
microscopic hematuria, progressive azotemia,
deafness)

 Nephrolithiasis imbalance of the

physiochemical state of the urine
Idiopathic hypercalciuria.
Renal tubular Acidosis,
Crohn disease/colitis
Hyperparathyroidism,
Gout,
Recurrent urinary tract infections (UTIs).

Other
Renal scintigraphy
estimate relative function of each kidney.

Positron emission tomography (PET)

CT
enhances staging, evaluation of recurrence versus
residual disease and response to therapy in
patients with testicular carcinoma.
In bladder cancer evaluation of metastatic
disease

RADIOGRAPHIC IMAGING FOR

GENITOURINARY DISEASES
Urolithiasis
The intravenous urogram (IVU) :
first sign of obstruction is delayed enhancement on the
affected side.
contrast fills the collecting system to the level of
obstruction

Noncontrast computed tomography (CT KUB)

rapidly evaluate patients with suspected stones to
determine size of stone and level of obstruction.
Almost all stones are radiopaque on CT

Ultrasonography
Determine the presence of hydronephrosis,
identify intrarenal stone

Trauma
CT- Scan
to evaluate pedicle or parenchymal injuries on initial scan
or collecting system injuries on delayed images.

One-shot IVU
demonstrate whether both kidneys are present and
functioning
contrast extravasation such as with penetrating injury

 retrograde urethrography
urethral evaluation Trauma patients who have
pelvic fractures

CT cystogram
performed by retrograde filling of the urinary
bladder with dilute contrast to voiding pressures.

Masses
IVU
to identify large parenchymal masses or
urothelial lesions.

CT Urogram
for small renal parenchymal masses.

Ultrasonography
detects most solid renal masses with
exception of very small or isodense ones
differentiate cystic from solid lesions.

 provide intraoperative guidance for localization or

cryoablation of renal masses.
with Doppler evaluation is the test of choice for scrotal
pathology from masses or inflammatory processes to torsion

MRI
aid in tissue characterization.
evaluates for intracellular lipid in adenomas; myelolipomas
(confirmed with fat saturation sequences).

PHYSIOLOGY OF VOI DING/VOIDI NG

DYSFUNCTION
Voiding Anatomy and Physiology
The lower urinary tract bladder, urethra, and
supporting structures, has two main functions:
bladder filling (urine storage)
bladder emptying

The muscle layers of the bladder, composed detrusor

smooth muscle fibers to exert maximal effective tension
over a wide range of fiber lengths.
the bladder is divided into two parts:
the body above the ureteral orifices (randomly arranged muscle
fibers)
the base trigone and bladder neck. (three distinct muscle layers)

These layers form a proximal physiologic sphincter

mechanism

 the muscular composition of the bladder neck and

urethra differ somewhat between males and females.
The outer longitudinal layer extends the entire length of
urethra (female ), ends near the membranous urethra (males)
middle smooth muscle layer, well developed and heavily
innervated by adrenergic fibers(male), poorly developed and
retains very little adrenergic innervation. (female)

these smooth muscle fibers are oriented in a circular

manner, allowing variations in urethral resistance
intrinsic portion of the distal sphincter mechanism.

 The voluntary or external sphincter is

composed of striated muscle fibers
extrinsic portion of the distal sphincteric
mechanism.
The external sphincter is also composed
of striated muscles of the pelvic floor,
including the levator ani and
pubococcygeus muscles.
The proximal or distal sphincteric
mechanisms can provide passive
continence in the male

 The most fundamental micturition reflex occurs

in the spinal cord stretching of the bladder
wall passage of urine
Central nervous control above the level of the
spinal cord occurs predominantly in the pons,
the basal ganglia, and cerebral cortex
The pontine micturition center (PMC) is the most
important motor center in voiding physiology
Centers located in the basal ganglia appear to be
primarily inhibitory to the detrusor muscle.
cerebral cortex exerts a primarily inhibitory influence
to the micturition reflex

 Urine storage sympathetic nervous system (T11-L2),

bladder emptying parasympathetic nervous system
(S2-4)
Parasympathetic, hypogastric and pelvic nerves pelvic
plexus, lateral to the rectum and internal genitalia
innervate detrusor muscle of the urinary bladder.
Sympathetic, superior hypogastric plexus, pelvic
plexus innervate the proximal sphincter
mechanism,intrinsic portion of the distal sphincter
mechanism.
The extrinsic portion of the distal sphincter mechanism
and the pelvic floor (levator) muscles,somatic motor
innervation pudendal nerve.

 Sensory neurons from the bladder are

divided into pain, temperature, and
proprioceptive sensation.
The sensory afferent neurons
bladder neck and trigone pelvic and
hypogastric nerves
external sphincter and urethra pudendal
nerve.

The Neurourologic Evaluation

Begins with a thorough voiding history
urgency, frequency, incontinence (irritative
symtoms)
poor urinary stream, hesitancy, and straining
(obstructive-type symptoms)
complete history of medical problems,
neurologic disorders
surgical and obstetrical procedures, and
trauma
voiding diary

 Physical examination emphasis on the

neurologic and GU systems.
gait
mental status
strength
sensation
reflexes
Deep tendon reflex
bulbocavernosal reflex (S2 to S4)

urinalysis and urine culture

Evaluation of the lower urinary tract can be

augmented
Cystoscopy rule out bladder anomalies or lesions
CT, intravenous pyelogram, or sonography gross
or microscopic hematuria patient
Urodynamic
capacity, accommodation, intravesical presure during storage,
intravesical pressure during voiding,
the presence and quality of detrusor contraction, the presence of
uninhibited contractions,
the perception of fullness, the ability to inhibit or initiate voiding,
the presence of residual urine

Classification of Voiding Dysfunction

three functional categories:
failure to store,
inappropriate loss of urine, decreased outlet
resistance, bladder overactivity, or poor
compliance.

failure to empty
pathology of the bladder itself or of the bladder
outlet

combination of both

 Decreased outlet resistance manifests as stress

urinary incontinence failure of urethral
resistance to compensate for transient increases
in intra-abdominal pressure (urethral
hipermobility, intrinsic sphincter deficiency (ISD)
Nonsurgical interventions -agonist or
sympathomimetic pharmacotherapy
surgically transvaginal and transobturator
sling procedures, pubovaginal slings,
intraurethral collagen injections, male slings,
artificial urethral sphincters.

 Detrusor overactivity urodynamically observed

involuntary bladder contractions occurring during
the storage phase
neurogenic or non-neurogenic in etiology;
infection, inflammation, bladder calculi, tumors,
and neurologic disease
The primary treatments for detrusor overactivity
are removal of the underlying cause and the use
of anticholinergic drugs
Surgical sacral nerve stimulation, bladder
augmentation, urinary diversion.

 Low compliance the ability of the

bladder to store urine at low, constant
pressures decreases.
Overflow incontinence results because the
high intravesical pressure exceeds the
outlet resistance pressure.
Detrusor hypertrophy, bladder wall
fibrosis, Injury to the pelvic plexus, Sacral
lesions below level S-2

ADULT URINARY TRACT INFECTIONS

Urothelial inflammation secondary to
microbial invasion.
The prevalence of UTI varies with age and
sex
Bacteria usually gain access to the urinary
system by an ascending route
UTIs can involve all parts of the urinary
tract

Lower Urinary Tract lnfection

Urethritis
dysuria, itch, and a purulent urethral discharge
sexually transmitted organisms

Cystitis
urinary frequency, urgency, suprapubic discomfort, and dysuria.

Prostatitis
can be either acute or chronic.
dysuria, difficulty voiding, urgency, fever, and perineal or lower
back discomfort.

Epididymitis
bacterial migration through the vas deferens long-term
urethral catheterization, urethral strictures.
scrotal pain, swelling, and tenderness
must be distinguished from the diagnosis of testicular torsion

Upper Urinary Tract Infection

Pyelonephritis
fever, chills, and flank pain,
Bacteremia may also be present and may
lead to sepsis
association of pyelonephritis with
vesicoureteral reflux is well established.

Evaluation
colony counts > 10 5 organisms per milliliter
was required to diagnose a UTI
Treatment
Treated with antimicrobial therapy
Renal or perirenal abscesses greater than 3
cm should be considered for drainage and or
surgical therapy.,

UROLITHIASIS
Calcium Calculi
low urine output (<1,500 ml/d),
hypercalciuria, elevated sodium or oxalate
excretion, increased protein intake, and
low urinary citrate excretion
increased absorption of calcium from the
bowel, or increased renal excretion of
calcium

Infection Calculi
composed of struvite or magnesium
ammonium phosphate
enzyme urease,urea ammonia.
irritates the epithelium creates a
substance called matrix capturing
magnesium ammonium phosphate and
calcium struvite

Uric Acid Calculi

Increased uric acid excretion
increased intake or turnover of protein
chemotherapy of lyrnphoproliferative diseases
patients with ileostomies
gout or other inherited disorders of uric acid
metabolism

Cystine Calculi
a defect in renal tubular handling of the
amino acids cystine, ornithine, lysine and
arginine (COLA).
Only cystine is insoluble at high
concentrations in the urine and thereby
calculi can form.

MALE INFERTILITY

 Factors that result in male infertility are

divided into pretesticular, testicular, and
post-testicular.
Pretesticular infertility is the result of
abnormal hormone production adversely
affecting spermatogenesis.
Isolated gonadotropin deficiency (Kallman
syndrome)
increased production of PrL (prolactinoma)
can result in abnormal spermatogenesis.
High levels of FSH in an azoospermic
postpubertal male

 Testicular causes of infertility

varicocele, orchitis, undescended testicles,
and toxic effects from exposure to agents,
genetic cause

Post-testicular causes of infertility include

problems with delivery of the sperm.
obstruction of the excurrent ductal system
(epididyrnis, vas deferens or ejaculatory
ducts) or disorders of ejaculation (retrograde
ejaculation or spinal cord injury).

ERECTILE DYSFUNCTION
The persistent or recurrent inability to
achieve and maintain an erection of the
penis sufficient for satisfactory sexual
performance.
Normal Erectile Physiology
Sexual desire or libido, which is maintained by
testosterone.
Arousal: during which penile erection occurs.
Orgasm/ejaculation: syrnpathetic signals
control ejaculation at the time of orgasm.
Resolution: tumescence.

Etiology of Erectile Dysfunction

Psychiatric disorder
Vascular disease (atherosclerosis, often
accelerated by hypertension, dyslipidemia, and
diabetes mellitus)
Medications (diuretics, B blockers, H2-blockers,
antiandrogens, protease inhibitors, cytotoxic
agents, SSRIs)
Pelvic and penile trauma
neurologie illness and anatomic abnormalities

Evaluation
History should elicit
presence and time course of ED,
evaluate cardiovascular risk factors, medications,
alcohol history, indices of depression, illicit drug use,
sexual history, psychosocial issues involving partners
and social stressors.

Physical examination
cardiovascular, neurologic, genital examination,
endocrine abnormalities

Testosterone, PrL and LH (If hypogonadism is

present)

Management
Initial therapy includes lifestyle
modifications
treatment of hypogonadism, medication
changes, counseling, assessment of
patient/partner expectations and
phosphodiesterase, (PDE-5) inhibitors.
Surgical therapy would include penile
prosthesis and surgical revascularization.

PEDIATRIC UROLOGY
Masses
hydronephrosis and multicystic dysplastic
kidney.
Neoplastic Wilms tumor and congenital
mesoblastic nephroma.
should be managed with surgical
resection.

Urinary Tract Obstruction

Posterior urethral valves (PUVs)
intravesical obstruction, can result in bilateral
dysplastic kidneys and renal failure.
frequently detected by antenatal sonography
Transurethral ablation of the valve, emporary
diverting vesicostomy

Congenital fetal hydronephrosis

evaluated postnatally with an ultrasonographic
and voiding cystourethrogram

Vesicoureteral Reflux
assessment of renal function with
radionucleotide imaging and selection of an
appropriate course of prophylactic antibiotics
Grading of reflux is generally after the
Dwoskin/Perlmutter classification.
Indications for surgical the inability to keep
the urinary tract sterile : extravesical
reimplantation and endoscopic periureteral
injection of dextraisomeryl hyaluronic acid
(deflux)

Spinal Dysraphism
After birth, require immediate assessment
with ultrasonography and a voiding
cystourethrogram
If the initial voiding cystourethrogram
demonstrates reflux, with or without poor
bladder emptying, intermittent
catheterization.

PEDIATRIC UROLOGIC SURGERY

Circumcision
Decreased risk of UTIs, elimination of the
potential for penile problems such as
phimosis and paraphimosis, decreased
risk for acquiring various sexually
transmitted diseases, and protection
against penile cancer.
The Gompco clamp, the Mogen clamp,
and the Plastibell device

Hypospadias
incomplete fusion of the urethral folds so that the
urethral opening is somewhere on the ventral
aspect of the penis or in the scrotum or
perineum.
Reconstructive surgery for hypospadias is best
done between the ages of 6 to 18 months.
The goals of surgery are to achieve a straight
penis with a normal urethral meatus at the tip of
the glans.

Cryptorchidism
Maldescent of the testicle may be noted at birth.
Some descend spontaneously during the first
year of life
Surgery should be done as soon as practical
after the boy becomes a year old.
Most undescended testes are palpable in the
groin, and inguinal orchidopexy is successful in
achieving the intrascrotal position

Testicular Torsion
surgical emergency abnormally mobile testis twists on
its vascular pedicle, resulting in ischemia of the gonad
experience onset of severe testicular pain
the testis and scrotum are usually exquisitely tender,
erythematous and swollen
Doppler ultrasonography diminished or absent
perfusion of the testis.
Emergent scrotal exploration should be done torsed
testicle appears to be viable, it is untwisted and fixed to
the scrotal wall, as is the contralateral testis.
testicular torsion is not corrected within 6 to 8 hours of
onset, infarct and necrotic.

Ambiguous Genitalia
congenital adrenal hyperplasia (CAH)
virilization of the external genitalia in females
enzymatic defect in the way the adrenal glands
metabolize cholesterol into cortisol
clitoral hypertrophy and labial fusion
Reconstructive surgery is usually undertaken
within the first year of life.
Feminizing genitoplasty consists of clitoral
reduction, creation of labia, and exteriorization of
the vagina.

Exstrophy-Epispadias
failure of fusion of the midline structures,
so that the pubic bones are separated and
the bladder is open and exposed.

GENITOURINARY TRAUMA
Renal injuries have been divided into five classifications by
the American Association for Surgery of Trauma:
Grade I, a renal contusion or bruise.Minor laceration
limited to the cortex.
Grade II, a minor laceration less than 1 cm in length
limited to the cortex.
Grade III, injuries involve a major laceration, greater than 1
cm in length, avoiding the collecting system.
Grade IV, injuries represent a major laceration of the
kidney involving the collecting system with urinary
extravasation. Vascular injuries of the segmental or main
renal vessels are classified as grade IV when the
hemorrhage is contained in the retroperitoneum.
Grade V, injuries are life-threatening emergencies and
include the shattered kidney or avulsion of the renal hilum.

 The indications for radiographic

assessment in the adult trauma patient
include
gross hematuria,
microscopic hematuria associated with shock,
clinical suspicion of injury (i.e., fracture of the
transverse processes of lumbar vertebra
and/or fractures of T-11 or T-12 rib),
splenic injury, and
penetrating injuries with any degree of
hematuria.

 The treatment of renal injuries is mediated

by the stage of the injury and stability of
the patient
Grade I through grade III injuries are selflimiting and usually resolve with conservative
treatment.
grade VI and V injuries, may require renal
exploration.

 Ureteral injuries account for approximately

1 % of GU trauma, and most are the result
of penetrating trauma.
direct examination of the ureter's full
course while the patient is being explored
Intraoperative ureteral canalization and
use of methylene blue may help identify a
more subtle site of urine extravasation.
IVU and CT will often, but not always,
show extravasation.

 Bladder injuries can occur as a result of

either penetrating or blunt trauma
classified as extraperitoneal ( 60 % ),
intraperitoneal ( 30 % ), or both ( 10% ).
85 % of bladder injuries are associated
with pelvic fracture
choice for evaluation of bladder injury is
the trauma cystogram.

 Posterior urethral distraction injuries occur

almost exclusively with pelvic fracture
presence of blood at the urethral meatus
and an impalpable or "high-riding" prostate
on rectal examination and perineal
ecchymosis.
The treatment consists of placement of
suprapubic urinary diversion and delayed
reconstruction.

 Anterior urethral injuries can be classified as

either contusions or disruptions.
Patients who have sustained straddle perineal
trauma shouldmbe evaluated with retrograde
urethrography
Many of these injuries can be managed initially
with placement of an indwelling urethral catheter
anterior urethral injuries resulting from
penetrating trauma mandate exploration,
debridement, and immediate reconstruction.
primarily reconstruct or divert and delay
reconstruction.

 Trauma to the external genitalia has been

classified by Culp as nonpenetrating,
penetrating, avulsion, burns, or radiation
injuries.

Congenital Bent Penis

Cause : hypospadias, hlperdistensibility of
the corporal bodies
can be ventral, lateral (left), dorsal, or
complex
Correction of curvature of the penis
caused by hypospadias involves resection
of the dysgenetic tissue.

Acquired Bent Penis

Usually a result of buckling trauma.
The surgical management either
shortening the long side or lengthening the
short side of the penis.

EVALUATION AND MANAGEMENT

OF BENIGN PROSTATIC DISEASE
proliferation of the epithelium and stromal
components of the prostate, afflicts most men
after the age of 50
clinical syrnptoms are referred to as LUTS
dynamic factor increased tone at the area
ofthe bladder neck and base, which leads to
obstructive symptoms ( -receptors)
The static component epithelial and stromal
hypertrophy (Dihydrotestosterone)
Surgical indications azotemia, recurrent UTIs,
recurrent hematuria, bladder calculi, and
refractory urinary retention

EVALUATION AND TREATMENT

OF GENITOURINARY TUMORS
Adrenal Malignancies
Rare and highly aggressive tumor, most
often occurs in the fifth to seventh decade
and in children younger than 5 years
Sixty percent of adrenocortical carcinomas
demonstrate endocrinologic activity
The only treatment shown to impact
survival is surgical resection.

Renal Neoplasms
Renal Cell Carcinoma
Renal cell carcinoma arises from the cells
of the proximal collecting tubule.
The primary treatment for renal cell
carcinoma is surgical excision.

Angiomyolipoma
Tuberous sclerosis is associated with
bilateral or multiple angiomyolipoma.
Presents clinically with hematuria and is
often detected by CT scans done for other
reasons
Surgery is appropriate if hemorrhage is
present or if the size exceeds 4 cm in'
diameter.

Wilms Tumor
Occurs predominantly in children
Chemotherapy has had a dramatic impact
on the survival of children with Wilms
tumors.

Cancer of the Bladder

presenting symptom of bladder cancer is
gross hematuria, bladder irritability and
dysuria
The critical staging distinction invasion
of the muscular wall of the bladder.
Superficial tumors are managed initially by
transurethral resection and fulguration.

 Muscle invasive transitional cell carcinoma

may be treated using a variety of options.
total or radical cystectomy, Partial cystectomy
External beam radiation therapy
chemotherapy protocol

periodic radiologic and cltologic monitoring

Carcinoma of the Prostate

Etiology and Pathogenesis
age and genetic predisposition, hormonal
factors, diet, environment, and possibly
infection and inflammation
The presence of testosterone appears to be
required for tumor initiation.
Prostate cancers are adenocarcinomas which
arise from the ductal acinar cells.

Diagnosis and Staging

PSA is helpful in the diagnosis of prostate
cancer and is indispensable for the followup of patients
CT scans of the abdomen and pelvis may
be used to demonstrate nodal metastasis.
Tumor grading is an important factor in the
prognosis of prostate cancer The
Gleason grading system

Treatment
localized disease may be treated by extirpative
surgery (radical prostatectomy),
external beam radiotherapy, interstitial
implantation cryotherapy (freeze-thaw
destruction).
hormonal therapy,

Malignant Tumors of the Testis

Seminoma
Most common tumor type, comprising
35% of all testis tumors.
incidence of B-human chorionic
gonadotropin (hCG) production in these
tumors.
treated with radical (inguinal) orchiectomy,
adjuvant radiation, multiagent
chemotherapy

Nonseminomatous Germ Cell Tumors

Embryonal cell carcinoma constitutes 20
% germinal cell tumors.
Two subtypes are seen: adult and the
juvenile embryonal cell tumor or yolk sac
tumor.
Teratomas contain more than one germ
cell layer in various stages of maturation.

 Testicular ultrasonography, B-HCG, Fetoprotein, LDH isoenzyme-1

Chest radiograph, CT scan, tumor
markers
metastasize to the retroperitoneal lymph
nodes around the renal hilum (except
choriocarcinoma)

 Initial treatment is inguinal orchiectomy for

all stages.
immediate retroperitoneal lymph node
dissection,
two cycles of chemotherapy, or active
surveillance.

Cancer of the Penis

Most often in the sixth decade , associated
with uncircumcised patients with longstanding poor hygiene.
Most penile cancers are squamous cell
tumors that first appear as raised ulcers
with an indurated base.
Treatment of the primary lesion is surgical.
This usually involves local excision, laser
therapy, or penile amputation.