Scope

• Anatomy

• Urologic Malignancies

• Trauma

• Emergencies

• Infections

• Lower Urinary Tract Obstruction

• Upper Urinary Tract Obstruction

• Pediatric Urology

• Key Points
Lower Urinary Tract
Obstruction
 Lower Urinary Tract
Obstruction

• Benign Prostatic Hyperplasia

• Urethral Stricture
Benign Prostatic Hyperplasia
• The symptoms of BPH are urinary frequency,
urgency, hesitancy, slow stream, and/or
nocturia.
• Over time, incomplete emptying may lead to
chronic bladder overdistension that can result
in a defunctionalized bladder.
• Medical treatment of BPH is usually the first
step.
• α-Blockers act on α receptors in the smooth
muscle of the prostate and decrease its tone.
• 5α-Reductase inhibitors, which block the
conversion of testosterone to the more potent Z,
shrink the prostate over several months.
• Transurethral resection of the prostate is the mainstay of
endoscopic surgical BPH treatment.
• When the prostate is very enlarged (>100 g), open surgical
procedures can be used.
• Suprapubic (simple) prostatectomy involves enucleation
of the majority of the prostate, but the capsule is left so
there is minimal effect on continence and erectile function.
 Benign Prostatic Hyperplasia
• Benign prostatic hyperplasia (BPH) is a
pathologic process that contributes tolower
urinary tract symptoms (LUTS) in aging men.
• Prostatic hyperplasia increases urethral
resistance, resulting in compensatory
changes in bladder function.
 Benign Prostatic Hyperplasia
• Obstruction-induced changes in detrusor
function, compounded by age related changes in
both bladder and nervous system function, lead
to urinary frequency, urgency, and nocturia, the
most bothersome BPH-related complaints.
• The size of the prostate does not correlate with
the degree of obstruction.
 Key Points

• Intraprostatic stents are confined to alternative therapy for BPH for

patients unfit for TURP.

• The holmium laser and the high-power PVP laser are efficacious in
improving PFR and IPSS, probably in a way that is comparable to TURP.
Long-term studies are required.

• TUVP and TUIP are also effective, particularly for small prostates.

• In well-trained hands, TURP is a safe and effective way of treating BPH,

with an acceptable side effect profile.
 Open Prostatectomy
• Considered when the obstructive tissue is estimated to weigh more than 75 g.
• If sizable bladder diverticula justify removal, suprapubic prostatectomy and
diverticulectomy should be performed Concurrently
• Large bladder calculi that are not amenable to easy transurethral fragmentation
may also be removed during the open procedure.
• Considered when a patient presents with ankylosis of the hip or other orthopedic
conditions that prevent proper positioning for TURP.
• In men with recurrent or complex urethral conditions, such as urethral stricture or
previous hypospadias repair, to avoid the urethral trauma associated with TURP.
• Inguinal hernia with an enlarged prostate suggests an open procedure, because
the hernia may be repaired via the same lower abdominal incision
Urethral Stricture
• Strictures may result from scarring due to infectious
urethritis, prior instrumentation, trauma, or cancer
• Diagnosis is by retrograde urethrogram or cystoscopy.
• They may be treated with dilation or transurethral incision,
but they have a tendency to recur after treatment.
• Open surgical excision is preferred for long or recalcitrant
strictures, and long-term success rates are excellent
 Urethral Stricture
• Anterior urethral disease, or a scarring process
involving the spongy erectile tissue of the corpus
spongiosum (spongiofibrosis)
• Posterior urethral stricture is an obliterative process in
the posterior urethra that has resulted in fibrosis and is
generally the effect of distraction in that area caused
by either trauma or radical prostatectomy
A retrograde urethrogram shows a totally
obliterative process involving the proximal bulbous urethra.
wide-caliber annular area proximal to the obliterative process of the
bulbous urethra
 Dilation

• Urethral dilation is the oldest and simplest treatment of urethral

stricture disease, and for the patient with an epithelial stricture
without spongiofibrosis, it may be curative.
• The goal of this treatment, a concept that is frequently forgotten,
is to stretch the scar without producing more scarring.
• The least traumatic method to stretch the urethra is to use soft
techniques over multiple treatment sessions.
 Internal Urethrotomy
• Internal urethrotomy refers to any procedure that opens
the stricture by incising it transurethrally.
• The urethrotomy procedure involves incision through the
scar to healthy tissue to allow the scar to expand (release
of scar contracture) and the lumen to heal enlarged.
• Many surgeons have learned to perform internal
urethrotomy by making a single incision at the 12-o’clock
position.
 Excision and Reanastomosis

• The most dependable technique of anterior

urethral reconstruction is the complete
excision of the area of fibrosis, with a primary
reanastomosis of the normal ends of the
anterior urethra
 Pelvic Fracture Urethral Injuries

• Pelvic fracture urethral injuries are the result of

blunt pelvic trauma and accompany about 10%
of pelvic fracture injuries.

• In these patients, the placement of an aligning

catheter may allow the urethra to heal virtually
unscarred or with an easily managed stenosis.
 Pelvic Fracture Urethral Injuries

• When the patient is successful in relaxing to void

and the cystogram outlines the posterior
urethra, a simultaneous retrograde urethrogram
nicely outlines the length of the injury defect.

• Primary anastomosis is the goal in all these

patients until it is proved impossible to perform.
 Pelvic Fracture Urethral Injuries

• The classic reconstruction consists of a

spatulated anastomosis of the proximal
anterior urethra to the apical prostatic
urethra.