Sabiston Textbook of Surgery, 19th ed

Transcription

Sabiston Textbook of Surgery, 19th ed
VGHTC
Sabiston Textbook of Surgery, 19th ed
Chief Round
報告 : R3 楊哲瑞
Contents
1
urologic anatomy for the general surgeon
2
endoscopic urologic surgery
3
urologic infectious disease
4
5
voiding dysfunction, BOO,BPH, and incontinence
male reproductive and sexual dysfunction
Department of Surgery
VGHTC
Contents
6
urolithiasis
7
urologic trauma
8
9
nontraumatic urologic emergencies
urologic oncology
Department of Surgery
VGHTC
VGHTC
Urologic Anatomy
for the general
surgeon
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™Upper Abdomen and Retroperitoneum
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™ the surrounding organs:
Right
Left
Posterior
12th rib
psoas muscle
11th~12th rib
psoas muscle,
Anterior
pancreas tail and splenic
Liver
vessels,
hepatorenal ligament
(coronary ligament) lesser sac and stomach,
jejunum,
duodenum,
splenorenal ligament
hepatic flexure of the
colon
Department of Surgery
VGHTC
UROLOGIC ANATOMY
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™URETER
Department of Surgery
VGHTC
UROLOGIC ANATOMY
ƒ Ureter
•
•
•
•
•
•
•
lie on the psoas muscle
pass medially to the sacroiliac joints
cross the iliac vessels anteriorly
swing laterally near the ischial spines
pass medially to penetrate the base of the bladder
vasa deferentia pass anterior to the ureters
uterine arteries are closely related to the lower ureters
ƒ blood supply
• The calyces, pelvis, and upper ureter: renal arteries
• The lower ureter: common and internal iliac, internal
spermatic, and vesical arteries
UROLOGIC ANATOMY
™Pelvic Anatomy: Bladder, Prostate,
and Seminal Vesicles
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™ BLADDER
ƒ Capacity: ~500 mL
ƒ Cephalad: urachus, a fibrous remnant of the cloaca
ƒ Superior: covered by peritoneal reflection
ƒ Inferior: attached to the pubic bone by puboprostatic ligaments /
pubovesical ligaments
ƒ Artery:
• hypogastric a.(internal iliac a.)Æsuperior, middle, and inferior vesical arteries
• vaginal and uterine a.
ƒ Vein:
• vesicle plexus Æ internal iliac v.
ƒ Lymphatics:
• The bulk of the lymphatic drainage Æ external iliac LN
• Anterior, lateral drainage Æ obturator, internal iliac node
• Base, trigone Æ internal, common iliac groups
ƒ transitional epithelial cell = urothelium = bladder mucosa
Æ lamina propria
Æ muscularis propria = detrusor muscle
UROLOGIC ANATOMY
™Pelvic Anatomy: Bladder, Prostate,
and Seminal Vesicles
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™ PROSTATE
ƒ Weight:~20 g
ƒ Anterior: puboprostatic ligament
ƒ Inferiorly: urogenital diaphragm
ƒ Posterior: Denonvilliers' fascia x2 layersÆ rectum
ƒ Zonal anatomy
•
•
•
•
•
•
peripheral zone
central zone
transitional zone
anterior segment(anterior fibromuscular stroma)
preprostatic sphincteric zone
*BPH develops from the median or lateral lobes, posterior lobe is
prone to cancerous formation.
ƒ ejaculatory ductsÆ verumontanum
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™ PROSTATE
ƒ Artery:
• inferior vesical a.
• internal pudendal a.
• middle rectal (hemorrhoidal) a.
ƒ Vein:
• periprostatic plexus, which has connections with the deep
dorsal vein of the penis and the internal iliac
(hypogastric) veins
ƒ neurovascular bundles (NVB): near the posterolateral
surface of the urethra and prostate gland
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™Groin, Genitalia, and Perineum
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™ Male urethra
ƒ 20 cm
ƒ four anatomic sections
•
•
•
•
Prostatic urethra
Membranous urethra
Bulbous urethra
penile urethra.
™ female urethra
ƒ 4 cm
ƒ lies below the pubic symphysis
ƒ anterior to the vagina
™ voluntary external urinary sphincter:
lies within the urogenital diaphragm
Department of Surgery
VGHTC
UROLOGIC ANATOMY
™ Spermatic cord, contains:
ƒ vas deferens
ƒ internal and external spermatic arteries,
ƒ artery of the vas
ƒ spermatic vein
ƒ Lymphatics
ƒ Nerves
™ epididymis
ƒ 1~3 seminiferous tubules Ærete testis in the mediastinum Æ12~
20 efferent ductules Æhead of the epididymis Æsingle coiled
duct of the epididymis
™ testis
ƒ 4 × 3 × 2.5 cm in diameter
ƒ Tunica albuginea, connects with the lobules within the testis
Ævisceral tunica vaginalis Æ serous tunica vaginalis
Department of Surgery
VGHTC
VGHTC
endoscopic urologic
surgery
Department of Surgery
VGHTC
Endoscopic
urologic surgery
™ Cystoscopy/cystourethroscopy(CUS)
ƒ rigid or flexible
ƒ adult
• 17Fr diagnostic rigid scopes
• 24 to 26 Fr operating resectoscopes
ƒ Cold cup biopsy forcep
™ Cone-tipped / straight ureteral catheter
ƒ Retrograde pyelography (RP): May be safely
performed to patients with a history of contrast allergy
ƒ To aid in identifying the ureters during surgery
Department of Surgery
VGHTC
Endoscopic
urologic surgery
™ Optical urethrotome: urethral stricture
incision
™ Electroresectoscope
ƒ cutting loop
ƒ Green Light laser
ƒ Holmium laser
ƒ bipolar resection system
ƒ Ellik evacuator
™ Continuous bladder irrigation (CBI)
Department of Surgery
VGHTC
Endoscopic
urologic surgery
Department of Surgery
VGHTC
VGHTC
Urologic Infectious
Disease
Department of Surgery
VGHTC
Urologic infectious
disease
™ Emphysematous Infection
ƒ DM
ƒ Emphysematous pyelonephritis
• fulminant infection involving the renal parenchyma progress
to involve the perinephric space
• most common causative agent: E.coli
• percutaneous drainage
• urgent nephrectomy: delay if improving with medical
treatment
ƒ Emphysematous pyelitis
• gas within the renal collecting system but not within the
parenchyma
Department of Surgery
VGHTC
Urologic infectious
disease
Department of Surgery
VGHTC
Urologic infectious
disease
ƒ Emphysematous cystitis
• gas-forming infection involving the bladder wall
• urinary catheter drainage
ƒ Acute papillary necrosis
• ischemic state involving the renal papillae
• sloughed papilla into the collecting system and
ureter, causing obstruction
• urgent drainage of the obstructed upper tract
ƒ Gas present in the urinary tract
• anaerobic urinary infection, instrumentation or
catheterization, colovesical fistula
Department of Surgery
VGHTC
Urologic infectious
disease
™ Xanthogranulomatous Pyelonephritis
ƒ foamy, lipid-laden, macrophage infiltrate in the renal
parenchyma
ƒ chronic bacterial infection, usually in the presence of
stones and chronic obstruction
ƒ poorly functioning kidney
ƒ fistulization to the flank or adjacent organs
ƒ drainage often are unproductive, Nephrectomy is
usually indicated
• “cooling off period” for active infection
• risk of iatrogenic adjacent organ injury is high
• the renal vessels cannot be individually dissected
Department of Surgery
VGHTC
Urologic infectious
disease
™ Epididymitis, Epididymo-Orchitis, Without
and With abscess
ƒ infected through ascending infection from the urinary
tract down the vas deferens into the scrotum
ƒ DDx:
• testicular torsion
• incarcerated inguinal hernia
• testicular tumor with necrosis and inflammation
ƒ Scrotal ultrasound
• abscess: surgical drainage +/- orchiectomy
• testicular ischemia: exploration +/- orchiectomy
Department of Surgery
VGHTC
Urologic infectious
disease
™ Fournier’s Gangrene
ƒ Necrotizing soft tissue infections of the genitalia
ƒ scrotal and genital pain, swelling, discoloration or
frank necrosis, crepitus, foul-smelling discharge
ƒ broad-spectrum antibiotic, supportive care, urgent
surgical debridement
ƒ separate the parietal tunica vaginalis of the testes
from the overlying necrotic dartos and skin and
preserve the tunical compartment intact
ƒ If the penile skin is necrotic, it can be débrided down
to but not through the Buck’s fascial layer
ƒ urinary tract source: urethral stricture with perforation
Foley
ƒ meshed STSG for the scrotum and nonmeshed thick
STSG for the penile shaft
Department of Surgery
VGHTC
Urologic infectious
disease
Department of Surgery
VGHTC
Urologic infectious
disease
™Genitourinary Fungal Infections
ƒ diabetics, immunocompromised patients
ƒ extensive nosocomial and antibiotic exposure
ƒ invasive fungal infections of the bladder or
kidneys may be life-threatening
ƒ antifungal bladder irrigation
ƒ fungus balls in the renal colleting
system:direct irrigation or endoscopic removal
Department of Surgery
VGHTC
Urologic infectious
disease
™Genitourinary Tuberculous Infections
ƒ Urine cultures from the first morning void
ƒ Upper urinary tract tuberculosis infection
• may cause ureteral strictures, result in silent
obstruction and renal loss
ƒ Tuberculous epididymitis
ƒ chronic epididymitis results in cutaneous
fistula formation
ƒ test for an immunocompromised state,
including HIV
Department of Surgery
VGHTC
VGHTC
Voiding Dysfunction,
BOO, BPH, and
Incontinence
Department of Surgery
VGHTC
Voiding dysfunction
™ Postoperative Acute Urinary Retention
ƒ Cause:
•
•
•
•
•
Immobility
Narcosis
anticholinergic side effects of anesthetic agents
underlying subclinical bladder outlet obstruction,
local pain and spasm (typical after hemorrhoid or groin hernia
surgery)
• transient prostatic swelling following coronary bypass surgery
or other procedures requiring cardiopulmonary bypass
ƒ Treatment:
• Catheterization voiding trial second catheterization +
indwelling Foley catheter for 1 or more days
• alpha blocker
• adequate analgesics
• urodynamic studies
• cystoscopy
Department of Surgery
VGHTC
Voiding dysfunction
™ Urinary Incontinence
ƒ Urgency incontinence
• loss of urine associated with an urge to void
• overactive bladder / detrusor instability
• anticholinergic / antimuscarinic
– SE: dry mouth, constipation, confusion
– Contraindication: narrow-angle glaucoma
ƒ Stress incontinence
• loss of urine with movement, straining, or increase in
abdominal pressure
• multiple vaginal deliveries, psot radical prostatectomy
• pelvic floor exercises, sling, artificial urinary sphincter
Department of Surgery
VGHTC
Voiding dysfunction
ƒ Overflow incontinence
• loss of urine when the bladder becomes full and
there is an inability to empty volitionally
• palpate the full bladder, measurement of postvoid
residual by ultrasound or catheter drainage
• the cause of the bladder distention: obstructive
versus detrusor dysfunction
ƒ Mixed incontinence
Department of Surgery
VGHTC
Voiding dysfunction
™Neurourology and Voiding
Dysfunction of the Neurologically
Impaired
ƒ cerebral dysfunction: uninhibited detrusor
function
ƒ cervical cord lesions: detrusor-sphincter
dyssynergia (DESD)
ƒ lower lumbar / sacral lesions: bladder
flaccidity and impaired emptying
Department of Surgery
VGHTC
Voiding dysfunction
™Benign Prostatic Hyperplasia and
Bladder Outlet and Urethral
Obstruction
ƒ LUTS (lower urinary tract symptoms)
ƒ little correlation between the measured
volume of the prostate and degree of
symptomatology that results
ƒ watchful waiting
Department of Surgery
VGHTC
Voiding dysfunction
Department of Surgery
VGHTC
Voiding dysfunction
ƒ medical therapy
• α-adrenergic blocking agents
– orthostatic side effects
• 5-alpha-reductase inhibitors
–
–
–
–
block the conversion of testosterone to dihydrotestosterone
reduce the actual volume of the prostate
alters the serum PSA level (reduces it ≈50%)
maximal effects seen by 6 months
ƒ minimally invasive
ƒ standard surgical intervention
• laser procedures
• TURP
• open simple prostatectomy
Department of Surgery
VGHTC
VGHTC
male reproductive &
sexual dysfunction
Department of Surgery
VGHTC
Male Infertility
ƒ Infertility affects 15% ~ 20% of couples
ƒ Male factor: 50% of these cases.
ƒ Hx:
• potential gonadotoxic exposure
• urologic and sexually transmitted infections
• trauma and prior surgery involving the pelvis, groin, and
genitalia
• family history of infertility
ƒ PE:
•
•
•
•
Masculinization
meatal location
testicular size
presence and normalcy of the
epididymis and vas deferens
• Varicocele
• DRE
Department of Surgery
VGHTC
Male Infertility
ƒ Semen analysis
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•
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•
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•
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semen volume
consistency
sperm concentration
sperm total count
percentage motility
quality of sperm movement
sperm morphology
presence of RBC/WBC/bacteria
ƒ serum hormone studies
•
•
•
•
•
FSH
LH
testosterone
free testosterone
prolactin
Department of Surgery
VGHTC
Male Infertility
ƒ azoospermia: complete absence of sperm from
the semen
• lack of sperm production
– normal semen volume
– elevated serum follicle-stimulating hormone (FSH) level
• defects in sperm transport or ejaculation
– ductal obstruction
» iatrogenic injury (e.g., inguinal hernia repair)
– ejaculatory dysfunction.
ƒ abnormal bulk semen parameters: reduced sperm
numbers, motility, or morphology
•
•
•
•
varicocele
antisperm antibodies
genital duct infection with pyospermia causing sperm dysfunction
gonadotoxic exposure
Department of Surgery
VGHTC
Male Sexual
Dysfunction
™40% of men at 40y/o and 70% of
men at 70y/o
™erectile dysfunction can be an early
indication of significant
atherosclerotic vascular disease
Department of Surgery
VGHTC
VGHTC
Urolithiasis
Department of Surgery
VGHTC
Urolithiasis
™ Risk factors
ƒ 20~50y/o, males, Caucasians and Asians
ƒ family history of stone disease
ƒ Low fluid intake (<1200ml/day)
ƒ High animal protein intake
ƒ Low activity levels
ƒ Chronic UTI
ƒ primary hyperparathyroidism
ƒ Sarcoidosis
ƒ Familial renal tubular acidosis
ƒ hyperoxaluria
ƒ cystinuria
ƒ inflammatory bowel disease
ƒ short gut syndrome
ƒ medullary sponge kidney
Department of Surgery
VGHTC
Urolithiasis
™Symptoms
ƒ acute onset pain, hematuria, and possibly
nausea, vomiting, and ileus.
™Image:
ƒ KUB: 90% of stones are radio-opacity
ƒ Ultrasound: hydronephrosis
ƒ non-contrast CT: the stone and the dilated
collecting system proximal to it
Department of Surgery
VGHTC
Urolithiasis
™Acute episodes: obstruction /
infection
ƒ Hydration
ƒ Analgesics
ƒ Decompressed urgently if with infection
• retrograde ureteral stent insertion
• percutaneous nephrostomy insertion
• Ureteroscopic lithotripsy is contraindicated.
Department of Surgery
VGHTC
Urolithiasis
™Treatment
ƒ Watchful waiting pilots
ƒ Extracorporeal lithotripsy (ESWL)
ƒ Intracorporeal techniques
• Ureteroscopic stone manipulation
• Flexible ureteroscopy and laser treatment
• Percutaneous nephrolithotomy (PCNL)
ƒ Open/Laparoscopic stone surgery
• Pyelolithotomy
• Anatrophic (avascular) nephrolithotomy
• Nephrectomy
Department of Surgery
VGHTC
VGHTC
Urologic Trauma
Department of Surgery
VGHTC
Urologic trauma
™Urologic injury
ƒ 10% of penetrating abdominal trauma cases
ƒ variable percentage of blunt abdominal
trauma cases
™Renal injuries
ƒ 1.4% to 3.25% of all trauma patients
ƒ 4% to 8% of penetrating trauma patients
Department of Surgery
VGHTC
Urologic trauma
Department of Surgery
VGHTC
Urologic trauma
™Renal Injuries
ƒ Imaging :CT scan
•
•
•
•
•
renal vasculature and of parenchymal lacerations
displaced or nonperfused parenchymal fragments
urinary extravasation
assessing function of the contralateral uninjured kidney
one-shot IVP may be obtained 10 minutes after the
injection of iodinated contrast
ƒ Treatment
• Grade 1 ~ 3:routinely managed nonoperatively
• Grade 4:controversial
– hemodynamic
– Interventional radiology options
• grade 5:operative intervention
Department of Surgery
VGHTC
Urologic trauma
™Ureteral Injuries
ƒ
ƒ
ƒ
ƒ
5% to 10% of penetrating abdominal trauma
uncommon in blunt trauma
gross hematuria may be absent
Imaging
• Contrast-enhanced CT + delayed excretory phase
• retrograde pyelography
• IVP
ƒ Treatment
• penetrating injuries / blunt avulsion: best managed by
surgical repair
• Ureteral contusions:
– prophylactic stenting to reduce progressive edema, occlusion, and
ischemia and postinjury extravasation
• avoid devascularization to prevent ischemic injury
• spatulated, tension-free anastomosis
Department of Surgery
VGHTC
Urologic trauma
™Bladder Injuries
ƒ Gross hematuria
ƒ Penetrating injuries with laparotomy planned:
• direct inspection of the injury site intraoperatively
ƒ Blunt trauma
• stress cystogram to distinguish intraperitoneal from extraperitoneal
injury
ƒ Extraperitoneal rupture
• pelvic fracture Æ tearing and shear forces related to injury to the pelvic
ring
• catheter drainage alone
• repair may be necessary when failure of catheter management
ƒ Intraperitoneal rupture
• sudden compression of the bladder by impact to the lower anterior
abdominal wall --> laceration of the bladder dome
• exploration and repair
ƒ Complex bladder injuries
• extensive lacerations of the bladder neck in women, or concomitant
injury to the lower bladder segment and rectum or vagina
• require operative repair
Department of Surgery
VGHTC
Urologic trauma
Department of Surgery
VGHTC
Urologic trauma
ƒ exploration of the bladder:
•
•
•
•
•
•
•
•
midline anterior cystotomy
examine interior of the bladder
evacuate blood clot
assess critical structures
– intramural ureters
– ureteral orifices
– passing feeding tubes up the ureters
– intraoperative retrograde pyelography
– bladder neck
close defects in the bladder wall in two layers
– care should be taken when suturing the bladder near
the ureteral orifices or intramural ureter
– intraoperative stenting
Injuries in continuity with rectal or vaginal injuries
– omental flap interposition to prevent fistula
diversion with a large-bore Foley catheter (22~24Fr)
suprapubic cystostomy tubes
Department of Surgery
VGHTC
Urologic trauma
™Urethral Injuries
ƒ suspicion of urethral injury
• blood per the urethra or blood at the urethral meatus
following blunt trauma
– pelvic fracture
– straddle injury with perineal impact
• penetrating trauma
– severe pubic diastasis
– marked vertical shear pelvic fracture
ƒ retrograde urethrography prior to Foley
catheter insertion
Department of Surgery
VGHTC
Urologic trauma
ƒ Treatment
• primary immediate goal: provide urinary bladder
drainage – suprapubic catheter
• early catheter realignment for posterior urethral
disruption
• delay repair
Department of Surgery
VGHTC
Urologic trauma
™Genital Injuries
ƒ Early exploration and repair
ƒ Penile injuries
•
•
•
•
remove foreign material
cleanse the wound
hemostasis
repair defects in the tunica albuginea or urethra
– Penile fracture: sudden flexion of the erect penis during sexual
activity
ƒ Scrotal and testicular injuries
•
•
•
•
•
scrotal ultrasound: whether the testis is ruptured
débridement of devitalized parenchyma
closure of the capsule (tunica albuginea of the testis)
repair of the scrotum
Orchiectomy
– thoroughly destroy the blood supply to the testis
– no viable parenchyma available to salvage.
Department of Surgery
VGHTC
VGHTC
Nontraumatic
Urologic Emergencies
Department of Surgery
VGHTC
Testicular Torsion
ƒ congenital deformity: “bell clapper deformity”
→able to rotate freely on its spermatic cord pedicle
→progressive edema and venous and arterial occlusion
→testicular infarction
ƒ occurring usually in the pediatric, adolescent,
and young adult groups
ƒ DDx:
• trauma,
• epididymitis,
• incarcerated hernia
ƒ Doppler ultrasound: absence of arterial flow
to the testis.
Department of Surgery
VGHTC
Testicular Torsion
Department of Surgery
VGHTC
Testicular Torsion
ƒ Best results: detorsion within 4 hours of the onset
of pain
ƒ 8 ~ 12 hours: testicular viability and function
decreases significantly
ƒ Ultrasound: within 1 hour after presentation
ƒ surgical exploration if high suspicion and
ultrasound is not available in a reasonable
time frame
ƒ scrotal incision Æ detorsion Æ orchiopexy Æ
orchiopexy on the contralateral side at the
same setting
ƒ Even a late torsion is suspected (e.g., several
days of fixed swelling, firmness), urgent
exploration is still indicated
Department of Surgery
VGHTC
™Gross Hematuria With Clot Retention
ƒ Surgical Emergency:
• with a hazardous degree of blood loss
• with urinary clot retention
ƒ Etiology:
•
•
•
•
post-OP bleeding after TURP /TURBt
radiation cystitis
pelvic trauma
arteriocalyceal fistula
Department of Surgery
VGHTC
™Gross Hematuria With Clot
Retention
ƒ Treatment
• large-bore (20 to 26 Fr), three-way Foley
catheter for removal of clots from the bladder
by catheter irrigation
• evacuation of clots under rigid cystoscopy and
resectoscope sheath
• fulguration
Department of Surgery
VGHTC
Priapism
™Definition:
ƒ Prolonged and often painful erection in the absence
of a sexual stimulus, lasting > 4~6h
ƒ may resolve spontaneously but, if it persists longer
than 2 to 3 hours, measures should be taken
™Etiology:
ƒ
ƒ
ƒ
ƒ
sickle cell disease
drugs
pelvic or genital trauma
hematologic malignancy
Department of Surgery
VGHTC
Priapism
™Low-flow priapism
ƒ Due to veno-occlusion, typical of sickle cell
patients
ƒ More common than high-flow priapism
ƒ sludging of blood in the corpora cavernosa results
in the accumulation of dark thick material
ƒ Ischaemic priapism > 4h: emergency intervention
ƒ Aspiration of blood from corpora:50ml portions
using a 18~20 gauge butterfly needle
ƒ Intracavernosal injection of α1 -adrenergic
agonist
ƒ medical treatment of the sickle crisis :
rehydration, oxygenation, analgesia, and
haematological input (consider exchange
transfusion).
Department of Surgery
VGHTC
Priapism
™High-flow priapism
ƒ after penile or perineal trauma
ƒ fistula develops between a central corporal
artery and the vascular space within the
corpus cavernosum
ƒ Aspiration: arterial appearance and arterial
blood gas parameters
ƒ cool bath / icepack
ƒ embolization of the internal pudendal artery
Department of Surgery
VGHTC
VGHTC
Urologic Oncology
Department of Surgery
VGHTC
urologic oncology
™Renal Tumor
ƒ Diagnosis
• solid renal tumors > 3 cm: 65% ~ 75% represent renal cell carcinomas
• Bx prior to surgical extirpation is reserved
• DDx:
– lymphoma
– minimally fat-containing angiomyolipoma,
– Sarcoma
– pseudotumor
ƒ Paraneoplastic syndromes: found in 20% of patients with
RCC
•
•
•
•
•
•
hypercalcemia
anemia
Stauffer's syndrome(Nonmetastatic hepatic dysfunction)
ESR elevation
*cytokine
*Hepatic function normalizes after nephrectomy: 60% to 70%
ƒ Cystic renal masses: Bosniak classification
Department of Surgery
VGHTC
urologic oncology
Department of Surgery
VGHTC
urologic oncology
™ Histologic Classification
ƒ Conventional
• Clear cell
• Granular
• Mixed
ƒ Chromophilic/papillary
• Type1
• Type2
ƒ Chromophobic
ƒ Collecting duct
• Medullary cell
ƒ Unclassified
ƒ *Sarcomatoid variants of almost all the histologic subtypes
Department of Surgery
VGHTC
urologic oncology
ƒ Partial nephrectomy
• small, well-encapsulated, superficial, exophytic, polar lesion
• positive margin and local recurrence rate: acceptable range < 5%
ƒ Radical nephrectomy
• multiple tumors, large central tumor, postoperative hemorrhage,
necrosis, or loss of collecting system integrity
ƒ Open, laparoscopic or robotic technique
ƒ +/- regional lymph node dissection
ƒ +/- splenectomy, distal pancreatectomy, wedge
resection of the liver, duodenum, partial resection
of the colon, resection of flank musculature
ƒ +/- renal vein or vena caval tumor thrombus
resection
Department of Surgery
VGHTC
urologic oncology
™Urothelial Cancer: Upper and Lower
Tract
ƒ Risk factors:
• age
• Tobacco smoking
• chemical exposures:
–
–
–
–
aniline dyes
aromatic amine compounds
rubber, leather, dye and petroleum workers
Cyclophosphamide
• chronic inflammation: SCC
• Schistosomiasis:Schistosoma hematobium:
SCC
Department of Surgery
VGHTC
urologic oncology
™Bladder cancer
ƒ TCC: 90%
• consider upper tract imaging
• long-term recurrence rate: 50%
ƒ SCC: 5% ~ 10%
• schistosomal infection
• chronic inflammatory
• smoking
ƒ Adenocarcinoma: 1% ~ 2%
• urachal in origin, typically seen at the upper bladder
dome
• history of bladder exstrophy
• evaluation of the GI system to ensure that the tumor has
not arisen from another organ system
Department of Surgery
VGHTC
urologic oncology
ƒ Symptoms:
•
•
•
•
•
gross painless hematuria: 75%
chronic irritative voiding symptoms
pelvic mass
flank pain: upper tract obstruction
flank mass
ƒ Dx:
• Urine cytology / bladder wash cytology
Department of Surgery
VGHTC
urologic oncology
ƒ Treatment:
• TURBt
• BCG intravesical immunotherapy: initial + maintenance
• Intravesical Chemotherapy: Mitomycin C
– immediately following standard TUR
• Radical cystectomy: muscle-invasive bladder cancer
– +/- neoadjuvant chemotherapy
– male: cystoprostatectomy
– female: cystohysterectomy
– +/- urethrectomy
– urinary diversion
» ileal conduit
» cutaneous catheterizable reservoirs
» orthotopic bladder substitution / neobladder:
Studer pouch
• Chemotherapy: MVAC or GC
Department of Surgery
VGHTC
urologic oncology
™Upper tract TCC
ƒ Treatment:
• Surgical resection
– +/- neoadjuvant chemotherapy
– Nephroureterectomy, including ureteral orifice
• distal ureterectomy + ureteral reimplantation
• endoscopic ablation
Department of Surgery
VGHTC
urologic oncology
™Prostate Cancer
ƒ Adenocarcinomas(95%)
ƒ Dx:
• Asymptomatic
• DRE, PSA, discovered incidentally during radical
cystectomy or TURP
ƒ Risk factors:
• family history : Y chromosome
• advancing age
• African American heritage
Department of Surgery
VGHTC
urologic oncology
™Prostate Cancer
ƒ Screening for prostate cancer: PSA and DRE
• recommended by the American Cancer Society
and American Urologic Association
• in all men older than 50 years
• with elevated risk factors: 40 / 45 years
• PSA
– normal-range
» 50 y/o: 2.5ng/mL
» 60 y/o 3.5ng/mL
– percentage of free PSA
» >25%: <10% risk
» <10%: >50% risk
– PSA velocity: <0.75 U/year
• improve survival, but controversy
Department of Surgery
VGHTC
urologic oncology
™Prostate Cancer
ƒ Dx:
• TRUS Bx
• Gleason score: two highest and most prominent
grades observed
• CT scan: lymph nodes metastasis
• Bone scan: bone metastasis
Department of Surgery
VGHTC
urologic oncology
™Prostate Cancer
ƒ Tx:
• localized disease
–
–
–
–
–
watchful waiting: low PSA level, low-grade, low-volume tumor
brachytherapy
cryotherapy
radical prostatectomy
External beam therapy
• advanced disease
– androgen ablation therapy
» luteinizing hormone-releasing hormone (LHRH) agonists
» bilateral simple orchiectomy
• Castration-Resistant Prostate Cancer
– chemotherapy
Department of Surgery
VGHTC
urologic oncology
™Penile, Urethral, and Other Genital
Malignancies
ƒ Penile cancer
•
•
•
•
Uncommon
SCC
chronic phimosis and local infection: HPV
circumcision, distal penectomy, or radical
penectomy +/- inguinal lymphadenectomy
ƒ Urethral cancer
• women > men
• TCC
• partial or total urethrectomy
ƒ Squamous cell cancers of the scrotum
• chimney sweeps: carcinogenic effects of inspissated soot
• Local excision
Department of Surgery
VGHTC
VGHTC