UROLOGY PART 2 SURGERY

Dr. GENLINUS YUSI MD, MMHOA, FPUA, FPCS

5.3
 In cases of nephrolithiasis, there is posterior shadowing.
Outline Posterior enhancement is different. Fluid tends to enhance UTZ
I. OBSTRUCTION AND URINARY STONE DISEASE
waves. The image in Figure 1 is an ultrasound image of a normal
• Hydronephrosis
• Urolithiasis kidney. In this case, the patient’s renal pelvis is slightly large,
II. HEMATURIA causing posterior enhancement.
• Causes of Hematuria
• Evaluation
III. UROTHELIAL AND BLADDER CANCER
• Bladder Squamous Cell Carcinoma

LEGEND
 Book  Recording  Previous Trans Must know
Important Concept

References:
1. Zoom Recorded Lecture by Dr. Yusi
2. Brunicardi, F. et al. (2019) Schwartz’s Principles of
Surgery .11th Edition, McGraw-Hill Education, New York
Journal (APA citation)
3.

Figure 2. Moderate Hydronephrosis as seen on UTZ

I. OBSTRUCTION AND URINARY STONE DISEASE
 This is not a normal anymore, this is hydronephrosis. There
should not be a hypoechoic area in the central echo complex.
I. HYDRONEPHROSIS
 This is an example of a patient with moderate
hydronephrosis. In cases of severe hydronephrosis, the
• Definition: “swelling of kidneys when urine flow is
parenchyma is paper thin.
obstructed in any part of the urinary tract.”
• Swelling of the ureter, which can accompany
hydronephrosis, is called hydroureter.
• Implies that a ureter and/or the renal pelvis are overfilled with
urine.
• May be seen on CT imaging or ultrasound, may range from
very mild to severe, with associated parenchymal thinning in
chronic cases.
 If it’s the kidney that’s swollen –that’s hydronephrosis; if it’s
the ureter – that’s hydroureter; if it’s both –
hydroureteronephrosis
 As hydronephrosis increases, the pressure within the
collecting system increases. However, the renal capsule is very
tight. What happens is that there will be thinning of the renal
cortex and some of the medulla. Eventual thinning renders the
Figure 3. Moderate to Severe Hydronephrosis as seen on
kidney functionless.
UTZ

Figure 1. Normal Renal Ultrasound.

Figure 4. Plain CT Scan (Axial View) – Pelvocaliectasia;
Moderate Hydronephrosis
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 SURGERY UROLOGY PART 2 LECTURE 5.3

 Figure 4. Is an example of pelvocaliectasia. Meaning the

renal pelvis is dilated. “Hindi na tusok-tusok yung calyces.”
There’s also a degree of parenchymal thinning.

Figure 5. Left Renal Calculi Figure 8. Intravenous Pyelogram

 There’s a calculi located maybe at the Utereropelvic joint  The left kidney is normal, the dye has already been expelled.
or the proximal third of the ureter. Most of the stones are The right kidney is severely hydronephrotic and most likely has
calcium-based, it’s as hyperdense as the bone. “Yan ang minimal functionality. It’s still functional, but minimal because it
maganda pag nagtitingin ng kidney stone using CT scan – was able to expel the dye even if it’s delayed.
kung hindi buto, most likely bato.”
 If you look closely at the right kidney, there is a stone which
probably contributed to the hydronephrosis.

 The question now is, why would the ureter be hydronephrotic

if the obstruction is at the level of the renal parenchyma? It may
be possible that there is recurrent urinary tract infection due to
the calculus, causing the ureters to be chronically inflamed
eventually would hypertrophy. We call this “intestinalization”
because the inflamed and hypertrophic ureters look like
intestines.
Figure 6. Contrast Enhanced CT – Coronal View
 There’s hydronephrosis only on the upper poles of the kidney. II. URINARY STONE DISEASE
This is most likely a duplex kidney. Although the lower moiety • Also known as Urinary Lithiasis
isn’t hydronephrotic, it’s not smooth. So, most likely there’s • “Stone belts” are geographic areas where urinary stone
damage from recurrent infection. disease is more prevalent
• Usually, areas where hot weather and dehydration are
common
• The North African-Asian Stone Belt – stretches from
Sudan, Egypt, Saudi Arabia, UAE, Iran, Pakistan, India.
Myanmar, Thailand, and Indonesia to the Philippines
• Worldwide prevalence is 3%;  This is actually high
• According to a study by REDCOP in 2004, estimated
prevalence in the Philippines is 6%.
 Prevalence is related to the general world population.
Incidence refers to the number of hospital consultations.
• 6% is 6000 patients with a diagnosis of urinary lithiasis per
100,000 of the general population.
• Thus, in a population of approximately 104,256,076 (July
2017 by the CIA World Factbook), means there are 6.3
Figure 7. Contrast Enhanced CT – Axial View million patients with urinary stone disease in the
 The left kidney is normal; there’s good enhancement, unlike Philippines.
the right kidney in which you can no longer see the parenchyma;
this is a paper-thin kidney that seems unfunctional.
 There is a chance for retrograde infection, affecting the
contralateral (normal) kidney .

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 SURGERY UROLOGY PART 2 LECTURE 5.3

A. RISK FACTORS • An old belief that too much Calcium can cause calcium
stones is not the case
• Individual Risk Factors
• Too much oxalates will cause this
o Non-Modifiable
 It’s the oxalate that you have to reduce not Calcium
▪ Family History
• Urinary Citrate is a strong inhibitor; prevents crystal
▪ Ethnicity
aggregation of calcium stones.
▪ Age
 Individuals who have low urinary citrates tend to be
▪ Gender
“stone formers”
o Lifestyle related factors:
▪ Diet
 Preventive treatments that we could give would be:
▪ Dehydration
▪ Overweight/Obesity • Supplements: Potassium Citrate
▪ Diabetes & Hypertension • Citrate Rich Food: lemonade, orange juice
• Environmental Factors: • Soda: The carbonic acid tends to increase urinary e.g.,
o Occupation Sprite, 7UP
o Geography o Avoid dark colored sodas: they tend to contain
o Climate and Temperature oxalate

 Metabolic Risk Factors: URIC ACID STONES

o Low Urine Volume. • Most common radiolucent and dissolvable stones
o Hypercalciuria  Not seen on x-rays; may be visible in CT scans
o Hyperoxaluria • Dissolution therapy can be done by alkalinizing the urine
o Hypocitraturia to a pH 6.5 to 7.5
o Hyperuricosuria • Alkalinizing agents:
o Cystinuria o Potassium Citrate
o NaHCO4
B. UROLITHIASIS • However, a normal renal function is needed with dissolution
• One of the most common conditions in Urology • Large uric acid stones may need some intervention to speed
• May affect 10% of the population over the course of a up the dissolution
lifetime  Shockwave lithotripsy
• Stones are crystalline aggregates of one or more  Laser lithotripsy
components, most commonly calcium oxalate. • Caused by Hyperuricosuria primarily but can be associate
with Hyperuricemia and Gout.
C. TYPES OF RENAL STONES  Not all patients with hyperuricemia are stone formers, and
not all patients with uric acids stones have gout.
CALCIUM OXALATE
• Frequently mixed with other kinds of stones.
• Stones frequently start out as uric acid nidus, and later
gets coated by calcium crystals
• Chemotherapy patients release purines into the urine
 You need to be vigilant, specially if they are stone formers.
Chemotherapy could accelerate stone formation.
NTH: Remember that purines (e.g., Xanthine) are precursors of uric acid
following metabolism.

Figure 9. Calcium Oxalate Crystals

• Comes in two main forms:

o Dihydrate
o Monohydrate – harder stone, more difficult
to fragment
 One of the main causes of failure of shockwave
lithotripsy
• Most common type Figure 10. Calcium Oxalate Stone with Uric Acid Nidus
• Calcific, thus visible on radiographs

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 SURGERY UROLOGY PART 2 LECTURE 5.3

STRUVITE
• Also referred to as “infection stones”
 These stones are usually non-obstructive. However, they
tend to grow into very large stones.
• Caused usually by urease-producing organism like
Proteus mirabilis
• E. coli, the most common UTI organism, is not urease
producing
• Urease cleaves urea, to ultimately produce ammonium Figure 12. Cystine Stones
which alkalinizes the urine. Phosphate precipitates and
forms Magnesium-Ammonium-Phosphate stones aka D. OBSTRUCTION
Struvite. • Formation of stones are more commonly within the
 The problem with these stones is they are NOT brittle. They calyces, which then drop into the urinary tract.
have a matrix similar to that of a cartilage, they are a little  They commonly form within the calyces but drop down to the
flexible. This property makes it difficult for the stone to be urinary tract in cases of increased urine flow and/or physical
fragmented by lithotripsy. activity.
• Has a tendency to create “staghorn” calculi  When they drop down, they lodge into the ureter, that’s when
• Forms a “cast” of the pelvicalyceal system making it appear they become symptomatic.
as a stag’s horn • Obstructing stones, usually in the narrower portions of the
• Usually non-obstructing, so hydronephrosis is not urinary tract (renal pelvis, ureter, ureterovesical junction
common. (UVJ) will cause severe, colicky pain.
• However, can still cause rapid renal failure due to the • Location of pain is dependent on the location of the
toxins produced by the pathogens stone.
• Stone is teeming with bacteria, so surgical treatment can • Major sites of renal stone impaction:
disseminate the infection more o Ureteropelvic Junction
 In surgical treatment, you must be very careful. Often, o Crossing of the iliac artery
struvite stones have biofilms on its surface. There is a tendency o Ureterovesical Junction
for dissemination of bacteria from the biofilm through
reabsorption of the vascular system causing sepsis.
 Preemptive measures would be:
• Prophylactic antibiotics
• Urine culture
• Blood culture

Figure 11. (Left)Struvite Stones, (Right) “Stag’s horn”

CYSTINE STONES
Figure 12. Major Sites of Renal Stone Impaction
• Caused by a homozygous recessive gene for cystine
transport, producing excess urinary cystine.
 Common in pediatric patients
• Cystine stones are the hardest stones, Difficult to fragment.
• Very rare in the Philippines
• Theoretically can be dissolved by alkalinization, however the
pH 8.5 (target pH) is difficult to reach and increases the risk
for Calcium Phosphate stone crystallization

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 SURGERY UROLOGY PART 2 LECTURE 5.3

(Non-contrast computed tomography). It is like

a CT scan counterpart of KUB IVP

• ULTRASOUND
o used for pregnant patients.

• CT UROGRAM
o Better modality since it can diagnose other
forms of obstruction
o Cannot be used in emergency settings
▪ Need creatinine test first
o Higher radiation exposure compared with
CTS
Figure 13. Distribution of pain in renal colic
 The American Radiology Association has given
 The pain is mostly on the flank but if the stone enters the
guidelines regarding radiation exposure for patients. You can do
ureters, the pain can radiate down from the flank down to the
up to 6 CT Stonograms safely in a year in a normal patient,
inner mid thigh. It’s very frequent that there is radiation of pain
conversely, you can only do 2 CT Urograms annually.
to the ipsilateral scrotum (males) and labia (women).

H. TERMS FOR MAKING THE DIAGNOSIS

 If the stone dislodges in the distal ureter, the quality of pain
will change. There will be decrease in pain but the patient will • Stones are described in the diagnosis according to area in
develop lower urinary tract symptoms (LUTS). the urinary tract + lithiasis
• NEPHROLITHIASIS
E. MANAGEMENT GOALS o Kidney stones or stones within the calyces
and infundibuli,
• The primary goal in an obstructed urinary tract is the
o Subdivided into:
relief of pain and obstruction.
▪ Superior
 You primarily manage the pain. Try to relieve the pain first
▪ Middle or
because this is the most troublesome for the patient. Once you
▪ Inferior Calyceal Calculi
manage the pain, you can then address the obstruction.
• PELVOLITHIASIS
 Don’ t keep the patient in pain for a long time
o Stones within the renal pelvis
 At times when pain cannot be managed, it usually is an
• URETEROLITHIASIS
emergency.
o Stones within the ureter.
o Subdivided into:
F. DIFFERENTIAL DIAGNOSIS OF ACUTE RENAL COLIC
▪ Proximal Third (P3)
RENAL OR URETERAL STONE ▪ Middle Third (M3)
HYDRONEPHROSIS ▪ Distal Third (D3)
(Ureteral junction obstruction, sloughed papilla) • PELVOLITHIASIS
BACTERIAL CYSTITIS OR PYELONEPHRITIS o Stones within the renal pelvis
ACUTE ABDOMEN • CYSTOLITHIASIS
(bowel, biliary, pancreas or o Bladder stones
aortic abdominal aneurysm sources)
GYNECOLOGIC
(ectopic pregnancy, ovarian cyst, torsion or rupture)
RADICULAR PAIN
(L1 herpes zoster, sciatica)
MUSCULOSKELETAL
REFERRED PAIN
(orchitis)

G. DIAGNOSTICS
• CT STONOGRAM:
o Gold standard is currently the CT stonogram
in the acute renal colic setting, in adults and
non-pregnant patients.
 The term CT Stonogram is only used in the
Figure 14. Stones based on their location
Philippines. The proper name is CT KUB/NCCT

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 SURGERY UROLOGY PART 2 LECTURE 5.3

 Definitely this is a kidney stone. You can see the stone inside
the collecting system and see the density (Hounsfield units). So
you can already make a diagnosis out of this.

Figure 15. Superior Calyceal Stone

 There is a shadow. Meaning that there is something dense Figure 18. Bilateral hydronephrosis
enough to stop the UTZ waves from passing through  This is a case of bilateral hydronephrosis but the right side
is worse. There’s also (L) Hydroureteronephrosis.

Figure 18. UVJ stone

 This is most likely UVJ Stone. The stone is probably at the
area of the ureteral orifice.
Figure 16. KUB Film
 This is a plain KUB film showing a calcific density at the area
of the left kidney. Incidentally, you don’t say “I can see a
pelvolithiasis.” You don’t know yet that this is a pelvolithiasis
based on this, so just described it. Unless you are really sure.
 What we should say is, “I see a triangular shaped calcific
density at roughly the area of the left kidney at the level of L1
behind the 12th rib, probably pelvolithiasis.”

Figure 19. Hydroureteronephrosis

 Mild hydronephrosis of the right kidney because of a UVJ
stone causing Hydroureteronephrosis

Figure 17. Renal calculi (right kidney) on CT

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 SURGERY UROLOGY PART 2 LECTURE 5.3

I. MANAGEMENT most struvite calculi may be temporized with antibiotics

1. INDICATIONS FOR URGENT INTERVENTION WITH without decompression, pending definitive treatment.
URINARY STONES
3. EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
• OBSTRUCTED UPPER TRACT INFECTION
(UROSEPSIS) • Non-invasive way of disintegrating the stones.
 How do we define urosepsis? Patients with symptoms of  The principle here is because our body is mostly made up of
obstructed urinary tract usually with high grade fever and chills. water, the shockwaves are propagated through the body.
Usually this indicates a severe infection that’s already in the  They made a way to create converging waves that passes
blood. Accompanying symptoms such as flank pain or history through an acoustic lens that redirects the waves to a focus.
of urinary tract infections could aid us in the diagnosis of a  If placed appropriately, the waves will eventually converge
condition that is of urologic cause. towards where the stone is located.
 If the stone is brittle, eventually it will be crushed.
• IMPENDING RENAL DETERIORATION (especially  The drawback in this procedure is that the patient must urinate
bilateral obstruction) the fragments. What if the fragments are too large? There is a
 Anuric patients due to bilateral obstruction. Usually, the possibility of stone impaction.
patient complains of pain and 4 days of anuria. Check if the  We don’t do this with patients who have very large stones.
bladder is distended (obstructive). Check for other causes. Our cutoff is usually 2cm in diameter.
Consider obstructions at the upper tract and pre-renal conditions  Since the waves converge to the kidneys, “kahit papano
that cause anuria (e.g., extreme dehydration) nagugulpi yung kidney. In cases of ureteral stones, pwede pa
lakasan kasi di naman masisira yun.”
 Success varies based on:
• PAIN REFRACTORY TO ANALGESICS o Number and density of the stones being treated
 More painful than labor. In labor there is periodic contractions o Specific ESWL machine used
unlike renal colic that is continuous. o Total number and rate of shocks given
o Stone size
• INTRACTABLE NAUSEA/VOMITING o Chemical composition
o Stone’s precise intra-renal location.
• PATIENT PREFERENCE
o ESWL is less successful for renal calculi
located in the lower pole compared to all
2. GENERAL CONSIDERATIONS
other renal locations
• In general, fully obstructed, or infected collecting o This is likely from the effects of gravity on
systems should be: fragment clearance.
o surgically decompressed either by: o Patients with lower pole stones are more
▪ Percutaneous Nephrostomy or likely to be stone-free if treated by
▪ Ureteral Stent Placement. ureteroscopy or percutaneous
• If the patient is unstable or septic: nephrolithotomy
o drainage of the blocked collecting system is
urgent and should be done emergently. 4. PERCUTANEOUS NEPHROLITHOTOMY
 Renal calculi in all other locations > 3 cm are best treated by
• Definitive treatment of the obstructing stone should be
percutaneous nephrolithotomy (PCNL), with or without adjunctive
delayed until any infection is well controlled.
ESWL
 PCNL involves initial placement of a small caliber
• Infection is suggested by:
nephrostomy catheter, under radiographic guidance, through the
o fever and elevated WBC count as well as a flank into the renal collecting system.
urinalysis showing pyuria and bacteriuria.
 The tract is then dilated, and a larger sheath is placed to
allow passage of either a rigid or flexible nephroscope into the
• Acute pyelonephritis cannot be reliably differentiated collecting system.
clinically from an infected kidney with an obstructing urinary  Minimally invasive procedure. We do a small incision, dilate
calculus: the track, put on a nephroscope, visualize the stone, then do
o Urological imaging (KUB, ultrasound or CT lithotripsy.
scan) is recommended in these cases to  Under direct vision, you can disintegrate the stone.
avoid misdiagnosis and a potentially  “Pwede din i-fragment muna, tapos pag maliit na, susungkitin
dangerous delay in surgical intervention. nalang palabas para tanggal na agad.”

• Infection proximal to an obstructing stone differs from an

infection (struvite) renal stone. In the absence of obstruction,

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 SURGERY UROLOGY PART 2 LECTURE 5.3

7. URETERAL CATHETERS AND STENTS

• Endoscopic placement of a ureteral stent, which is a
temporary plastic tube with curls on each end to prevent
migration.
• Stents allow flow both through the lumen and around it.
• When chronic stenting is required, it must be changed every
3 months to prevent severe encrustation with urinary
sediments.

Figure 19. Percutaneous Nephrolithotomy CATHETER STENT

A tube in which one end is A tube in which both ends are
inside a biological tube within the body.
5. FLEXIBLE UTEROSOPY WITH LASER LITHOTRIPSY
(bladder) while the other end
 Instead of going percutaneously, we go through the is outside (drain)
RETROGRADE APPROACH – from the urethra -> ureter ->
kidney using a flexible scope.
 Done under spinal anesthesia
 Most stones can be located and removed or fragmented into
tiny pieces (< 1 mm) that can pass painlessly.
 Stone-free outcomes result in over 90% of cases of ureteral
calculi after a single ureteroscopy procedure.
 Technically more challenging, with stone-free outcomes of
60 - 84% after a single procedure.
 In general, the success rate diminishes as stone size
increases and multiple procedures are usually required for renal
calculi > 2 cm.

Figure 22. “Double J” Ureteral Stent. It’s called Double J

because there is a distal and proximal curl to prevent migration.

Figure 20. Semi-rigid Ureteroscopy. The semi-rigid

ureteroscope is more common in the Philippines due to its lower
cost compared to the Flexible Ureteroscope

6. OPEN SURGERY
 The last alternative treatment.
 This is done with the patient under general anesthesia and in
lumbotomy position to make the kidneys more superficial.
 We angle the table and put a kidney rest at the level of the
posterior superior iliac crest – making the kidney more superficial
and accessible

Figure 23. “Double J” Ureteral Stent (KUB Xray) You check

if both curls are deployed. “if straight yan, baka nasa
ureter/renal pelvis palang.” The tip will naturally curl if it’s
properly placed.”

Figure 21. Lumbotomy position.

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 SURGERY UROLOGY PART 2 LECTURE 5.3

J. PREVENTION AND MANAGEMENT COMMON CAUSES OF GLOMERULAR HEMATURIA

• Drink water throughout the day • IgA nephropathy (Berger’s disease)
• Thin glomerular basement membrane disease
• Eat fewer oxalate-rich foods
• Hereditary nephritis (Alport’s syndrome)
• Choose a diet low in salt and animal protein
• Continue eating calcium-rich foods, but use caution with COMMON CAUSES OF NON-GLOMERULAR
calcium supplements HEMATURIA

HEMATURIA Upper Tract Lower Tract

 Hematuria is technically not a diagnosis. It is a symptom. ▪ Urolithiasis ▪ Bacterial cystitis (UTI)
• Hematuria is defined as the presence of red blood cells in the ▪ Pyelonephritis ▪ Benign prostatic
▪ Renal cell cancer hyperplasia
urine.
▪ Transitional cell ▪ Strenuous exercise
• When visible to the patient, it is termed Gross Hematuria. carcinoma (“marathon runner’s
 When we say gross hematuria it’s a little bit more alarming ▪ Urinary obstruction hematuria”)
• Can appear bright red, to pinkish, up to cola or tea colored. ▪ Benign hematuria ▪ Transitional cell carcinoma
 If there is active bleeding specially in the bladder it can come ▪ Spurious hematuria (e.g.
out as bright red (fresh blood). If it’s old blood, it can come out as menses)
▪ Instrumentation
tea colored, black or coca cola similar to melena.
▪ Benign hematuria
• Microscopic hematuria is detected by the dipstick
method or microscopic examination of the urinary  When we say UTI, it is referring to general infection of the
sediment. Defined as: whole urinary tract. When you say cystitis that’s inflammation in
• Dipstick Blood (+): the bladder.
▪ Note that it will also show positive in  BPH can produce some microscopic hematuria.
myoglobinuria & hemolysed Hb  Even strenuous exercise - marathon runner’s hematuria
• Microscopy:  Transitional cell CA (bladder/ureter) also presents with
▪ > 3/hpf (flow cytometry) or hematuria.
▪ > 5/hpf (light microscopy)  There’s also spurious hematuria, in cases menstruating
• Hematuria must be thoroughly evaluated. women. You always have to ask when their last period was.
• Causes can be from the simplest to the most serious. (ie:  Instrumentation can also cause hematuria (after catheter
UTI to Malignancy) insertion). That’ why I don’t order urinalysis after a procedure
• Ex: Urinary Tract Infection, Urinary stone disease, like this. It will be useless.
Renal or Urothelial cancer.  Benign hematuria should always be investigated periodically.
 You should not forget that there are patients who just have
hematuria - Idiopathic hematuria. Usually they have microscopic HEMATURIA RISK FACTORS
hematuria. In cases like this after doing a thorough evaluation,
• Hematuria pts should be classified as Low or High Risk
“wala kang makikita.” Don’t forget patients like these. You must
evaluate them periodically (at least once a year.) Because there • High Risk Factors:
might be a chance that during your prior assessment, they were o Age >40 years
just subclinical. o Male gender
o Hx of cigarette smoking
o Hx of chemical exposure
ETIOLOGY
o Hx of pelvic radiation
• Hematuria pts can also be classified as Glomerular or o Irritative voiding Sx (urgency, frequency, dysuria)
Non-glomerular. o Prior urologic disease or treatment
• Glomerular Hematuria, is usually the concern of the  If you have any 1 or even more of all of these, you are now
Nephrologist. classified as high risk
• Non-Glomerular, is usually the concern of the • 10% chance of documenting a malignancy in pts with
Urologist, and can be further subdivided into: asymptomatic microhematuria
▪ Upper tract – kidney & ureter  10% chance is large enough and it’s worth it to investigate
▪ Lower tract – bladder & urethra these asymptomatic pts esp the one in the high risk group

HEMATURIA EVALUATION
• Pts are considered High Risk if with gross hematuria
and/or any of the High-Risk factors
 If the pt has gross hematuria no matter what, they are already
high risk. You have to investigate regardless.
• Pts are considered low risk if with Asymptomatic
Microscopic Hematuria with none of the High-Risk factors.
• Succeeding evaluation depends on the risk
stratification
• For Low Risk:
Figure 24. Dysmorphic RBC(left), RBC cast (right) o Renal ultrasonography
 If you see these, they are usually glomerular in origin. ▪ Masses, nephrolithiasis,
hydronephrosis
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 SURGERY UROLOGY PART 2 LECTURE 5.3

o Regular follow-up with: chance of obtaining suspicious or

▪ Urinalysis and renal ultrasonography cancer cells.
 For low risk madali lang, just do renal ultrasonography and
regular follow-up. If negative just have them follow-up 1x a year
just to be sure.
 REMEMBER that one of the criteria is age. Age >40 is high
risk.

Figure 27. Cystoscopy

 This a flexible
cystoscope and can be
manipulated/bent. This
is done under local
anesthesia. May be
done in the clinic. It’s like
inserting a foley catheter
and the cystoscope is
connected to a monitor.
Figure 25. (M) Solid renal mass (left), Yellow arrow: Stone
with posterior sonic shadowing (right)

Figure 28. Ureteroscopy

 The ureteroscope is
thinner and the image is
smaller. We also use this
for stones for retrograde
intrarenal surgery.

Figure 26. Hydronephrosis, dilated calyces, loss of central

echo complex
 These are the things that you can catch in your ultrasound
that can cause hematuria. Figure 29. Irregular filling
defect in renal pelvis & upper
• For High Risk: ureter
o Contrast-enhanced imaging of the kidneys  There is filling defect inside
and ureters (CT Whole Abdomen or CT the renal pelvis, and there are
Urogram)  You need to get a creatinine test inserts going down and this is
result before you can do a CT Urogram.” very suspicious.
o Urine cytology  It’s like urinalysis but the
sample you have to get here is the first voiding
in the morning (not just the midstream – you
collect all). It has to be done fresh, so you
immediately send it to the laboratory.
o Cystourethroscopy  Done specially if the
patient is high risk. Better to do this when Figure 30. Fungating
there is active bleeding. It will be useless if the mass with papillary
bleeding stopped e.g. a week ago. fronds
▪ Done IF Imaging &/or cytology is  Following cystoscopy,
suspicious for ureteral pathology this is what transitional
▪ Retrogade Ureterograms &/or cell CA looks like. We
Ureteroscopy is done along with the describe them as papillary
cystourethroscopy fronds. As you can see at
▪ Bladder &/or Ureteral Barbottage (or the center, there are
“wash”) is done, and sent for reddish papules and each of those things have their own
cytology  If you have a suspicion blood supply. As opposed to bullous edema which does not
but the urine cytology is negative, yo have a blood supply. This looks very malignant.
can increase the yield of cytology
using a bladder wash. Flushing out
the epithelium there’s a higher
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 SURGERY UROLOGY PART 2 LECTURE 5.3

 Even if everything is negative you have to ask the patient for

follow-up. In my practice, I request for ultrasound yearly, but
after 2 years I order for CT-urogram or cytology for a more
comprehensive test. “Hindi mo pwede tantanan yang mga
hematuria patients because there’s always a chance that it turns
out to be a very early case of cancer.”

III. UROTHELIAL AND BLADDER CANCER

 The reason why these 2 are grouped because they are in
the same pathology. It’s the location that differs but both have
the same pathology - Transitional Cell Carcinoma.
 Urothelial Cancer – cancers in the urinary tract starting
urothelial cells to the renal pelvis to the ureters.
 Bladder Cancer – if the lesion extends to the bladder.
 It is the second most common urologic malignancy.
• Most common pathology is Transitional Cell Carcinoma
(TCCA). However, there are instances that there can be
Figure 31. Ureteroscopy of a ureteral tumor Squamous cell carcinoma or adenocarcinoma.
• Aside from the bladder, other sites with Transitional Cell
Epithelium can be involved, such as the Ureter, Renal
Pelvis and Calyces.
• Aka. Transitional Cell Carcinoma  Its difference from
Renal Cell Carcinoma is that it has the tendency to seed.
So if you have TCCA in the upper tract, it has a tendency to
seed downwards.
• Highly associated with:
o Tobacco use:
o  confers a 2-to 3- fold increased risk of
developing cancer.
o Exposure to other carcinogenic materials such as
automobile exhaust or industrial solvents.
o Other risk factors include arsenic, radiation,
cyclophosphamide and chronic exposure to foreign
bodies (stones and catheters) and specific urinary
parasites.
o Age – median age is at 70 years
• Urothelial Cancer
Figure 32. Urothelial carcinoma in-situ o  Most common bladder cancer accounting for
Voided urine cytologic sample in group 4 (malignancy) 90% of tumors but tend to have a better prognosis.
A. Papanicolaou, ×600 o 80-90% presents with gross hematuria.
B. p16INK4a immunocytologic stain, ×600 o Some would have irritating voiding symptoms
C. H&E, ×200 (frequency, urgency, nocturia)
D. p16INK4a immunohistologic stain, ×200  There is no reliable screening test for bladder cancer. Office
cystoscopy is an effective means to diagnose bladder cancer
Histologic diagnosis was urothelial carcinoma in situ.
Overexpression of p16INK4a was detected by cytologic and I. BLADDER SQUAMOUS CELL CARCINOMA
histologic examination (score, 3+). • Usual Etiology: Chronic irritation from catheters, bladder
stones etc.
 This is what you’ll see using with urine cytology. In
Histopathology they can put Papanicolaou stain and other  Arise from areas which are usually chronically irritated or
different stains to identify urothelial carcinoma esp. carcinoma in dirty. The continuous cycle of irritation, damage, and repair
situ(which is basically a layer of cancer kaya wala kang contribute to the generation of mutant cells and lead to
makikitang mass mas) makukuha mo yan sa bladder wash. development of squamous cell carcinoma.
You’ll only be able to visualize characteristics such as reddish • A known unique etiologic agent of bladder squamous cell
or bloody tissue samples but there will be no mass lesions. The
carcinoma is Schistosoma haematobium.  This is very
thing about carcinoma in situ is that its cells are easily sloughed
off. uncommon here in the Philippines but common in Egypt.

HEMATURIA EVALUATION
• With this strategy, a cause will be identified in 80% of cases,
with 20% of asymptomatic cases will be diagnosed with a
urologic cancer.
• Persistent hematuria after a negative initial evaluation
warrant repeat evaluation at 48-72 months since 3% of this
group will be subsequently diagnosed with a urologic
malignancy.
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 SURGERY UROLOGY PART 2 LECTURE 5.3

AN\
Figure 33. Bladder mass as seen in UTZ

 This is a bladder UTZ, as you can see there is this mass

lesion that is fixed in the inferior portion of the bladder. Now, how
can you distinguish between a bladder mass and a hematoma? Figure 36. Urinary Bladder tumor as seen in MRI
 The main difference is “pag pinagalaw mo yung patient,
yung hematoma gagalaw pero ang bladder cancer hindi.” It  This is an MRI showing a tumor inside the bladder occupying
would be in the same position no matter how you turn the almost half the urinary bladder.
patient.

Figure 37. Urinary Bladder tumor as seen in MRI

•  This is also an MRI. You can see almost the entire bladder
is involved. They look multifocal. So that’s the problem with
TCCA, it usually seeds to other sites. So usually in surgery hindi
Figure 34. IV Pyelogram
naming pinapasok yung urinary tract kasi kapag napasok yung
ihi at nagexpel in the operating field, pwede kang magupstage –
 This is a IV pyelogram/IV urogram. (a) This is a 20 min film
suddenly kalat na yung transitional cell carcinoma.
because you have a lot of urine in the bladder. Kapag 10 mins
konti palang yung ihi perong kitang kita na yung kidney. Here
what you can see is your filling defect at the right inferolateral
portion. So, this is radiolucent. Kasi kapagKUB film wala kang
makikita dito, this would be blank kaya that’s why we like to have
a contrast lalabas siya. (b) post-residual urine so pagkatapos
niyang umihi nakikita parin siya.

Figure 38. TNM staging

Figure 35. Bladder mass as seen in UTZ  This is the staging in Transitional Cell Carcinoma. The staging
depends on how deep the intraluminal mass is. Bladder
 This is an axial CT scan without contrast showing a larger cancer usually starts inside. What’s important here is how deep
fungating mass at the floor of the bladder posterior to left the cancer went through. Muscle layer is the factor the
lateral. This usually turns out to be cancer. determines invasiveness. If the epithelium or lamina propria is
involved superficial palang. Once it penetrates the muscle, it’s
already invasive, we have to do some major surgery.

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SURGERY UROLOGY PART 2 LECTURE 5.3

STAGING OF DISTANT METASTASIS

• M0- No signs of distant spread.
• M1: The cancer has spread to distant lymph nodes, organs,
tissues (like the bones, lungs, or liver)

MANAGEMENT
• Trans-urethral Resection of the Bladder Tumor (TURBT)
o Is actually both diagnostic and therapeutic
o For superficial bladder tumors(T1), TURBT can be
curative. However, there is still a need to do
intravesical chemotherapy.
 Principal form of diagnosis and therapy for bladder cancer.
 Should include an examination under anesthesia and
sampling of the bladder muscular wall to fully assess depth of
invasion.
Figure 39. TNM staging 2
 The presence of induration or a mass on EUA denotes
extravesical tumor extension and may alter patient’s treatment
 Here is the staging of TCC. Ta – lamina propria, T1 is the
plan.
transitional cell epithelium. When it gets to T2 nasa muscle na
 It may also be appropriate to biopsy multiple areas of
siya. Ta and T1 is superficial. T2a- T3b is invasive.
mucosa to identify multifocal carcinoma in situ.
 Restaging TURBT within 2 to 6 weeks is recommended
in patient with incomplete, under-sampled, or uncertain
resection.

Figure 40. Transitional Cell CA as seen through

Cystoscopy Figure 41. Diagram of TURBT
 This is the trans-urethral resection of the bladder tumor
 They are very similar in appearance even if the images are wherein you have here the resectoscope. You will not scrape the
taken from different patients. It’s also very important to describe prostate; you will scrape the bladder. You must be careful in
the base of the tumor (pedunculated or sessile?) because they scraping the urinary bladder as well to prevent perforation of the
indicate different prognosis. deep layer (avoid this because you’ll be doing ex-lap if this
happens).
• T1- (Non- invasive) disease
CLINICAL STAGING OF BLADDER CANCER
o Can be managed by TURBT alone
• CT/MRI – to assess intraabdominal nodal and visceral sites of
o However, there may be a high risk for recurrence or
metastasis.
progression to T2 disease.
• CT urography or retrograde pyelography- to evaluate upper
tracts • Patients with HIGH GRADE tumor or Recurrent disease
• Chest radiograph- initial evaluation of thorax and mediastinum may benefit from Intra-vesical Chemotherapy.
• Bone scan- if patient complains of bone pain, has known o BCG (Bacilli-Calmette-Guerin)
locally advance or metastatic disease or unexplained ▪  It provides a significant reduction in
elevation of ALP. recurrence in a greater than 50%
▪  We infuse the strain into the bladder. This
STAGING OF PELVIC LYMPH NODES induces a cell-mediated immune response on the
• NX- regional lymph nodes cannot be assessed due to lack of bladder mucosa. The resulting inflammation aids
information. in getting rid of the residual disease.
• N0 – No regional lymph node spread. o Mitomycin C
• N1- The cancer has spread into single lymph node in the true
o Docetaxel
pelvis.
• N2- The cancer has spread to 2+ nodes in the true pelvis. ▪  Both are quite good specially when
• N3- The cancer has spread into the lymph nodes that lie along combined. Given immediately after TURBT.
the common iliac artery. Very benign side effects.

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 SURGERY UROLOGY PART 2 LECTURE 5.3

• Invasive bladder CA  We isolate a segment of the ileum (the ileum is the best
o T2+, where the tumor invades the muscularis, removal segment of the intestine to use for this). We get 6-10 cm of ileum
of the part of the entire bladder becomes necessary. and maintain the blood supply of that segment. We cut and then
reconnect the remainder of the intestine. The isolated segment
o Partial Cystectomy – for invasive but solitary tumors
of the ileum is immobilized, and we implant the ureters to one
that involve the dome of the bladder(T1-2). end of the ileum, and other end is exteriorized into the skin.
 This are only limited and generally apply to
isolated tumors or those within diverticulum.  This is a Urostomy (kasi ihi yung lumalabas) a counterpart
of the Colostomy bag.

Figure 42. Partial Cystectomy

 If the tumor is only in one area, we can do partial cystectomy.

We resect a part of the bladder with a 2cm margin then do frozen
section to investigate for microscopic spread. We can only do Figure 44. Urostomy bag
partial cystectomy if the mass is solitary, if it is located at the
dome, far from orifices, and far from the bladder neck. COMPLICATIONS OF BLADDER SURGERY
o TURBT – bladder perforation
o Radical Cystectomy o Cystectomy and urinary diversion – prolonged ileus, bowel
o In men, Radical cystoprostatectomy – where the obstruction, intestinal anatomical leak, urine leak or rectal
bladder and prostate are removed en bloc. injury.
▪ Current long term cure for clinically localized o Cystectomy- deep venous thrombosis
disease is still only 50-60%.  Alternatives to cystectomy include observation, systemic
▪ Neoadjuvant or adjuvant chemotherapy in chemotherapy, radiation therapy, or a combination of
those without discernable metastatic spread chemotherapy and radiation therapy. These may be offered to
may be of benefit. patients who are poor surgical risk, refuses surgery and elderly.
▪ Limited lymph node involvement may be cured
with surgery alone, but those with extensive  More recently, Immunotherapeutic treatments have shown
lymph node involvement have a dismal significant promise in the treatment of locally advanced and
prognosis. metastatic bladder cancer. 5 agents were approved for patients
 Radical cystectomy remains the most effective who have improved or after platinum chemotherapy or have
single-modality treatment for patients with muscle progressed into 12 months of neoadjuvant or adjuvant
invasive bladder cancer, refractory high risk non- chemotherapy and this includes:
invasive bladder disease and especially lymph node- o PD-L1 inhibitors (atezolizumab, avelumab,
negative disease. durvalumab)
o In women, Anterior Pelvic Excenteration – where the o PD-1 inhibitors (Nivolumab, pembrolizumab)
bladder, uterus and ovaries are removed en bloc.
-END OF TRANS-

NUGGETS
Urine culture >100,000 colonies,
diagnostic for UTI
Drooping lily sign, or cobra Ureterocele, and ectopic
sign ureters
Microscopic hematuria >3 RBC/hpf on 2 of 3
specimens
Irritative voiding symptoms Urgency
Frequency
Dysuria
Figure 43. Invasive Bladder CA Glomerular hematuria Dysmorphic red blood cells
(also red cell cast)
o What will happen to the ureters? Where will the urine flow Common causes of IgA nephropathy (Berger’s)
through? glomerular hematuria Thin glomerular basement
▪ The ureters are attached to an isolated segment membrane disease
of the ileum. Hereditary nephritis
(Alport’s)
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SURGERY UROLOGY PART 2 LECTURE 5.3

Most common cause of Berger’s

asymptomatic glomerular
microhematuria
Most common cause of Transitional cell carcinoma
nonglomerular
asymptomatic
microhematuria in urinary
bladder
Used to examine lower Flexible cystoscopy
urinary tract in hematuria
cases
Screening for hematuria Voided urine cytology
Renal UTZ
Higher yield than voided Bladder wash, or barbotage
urine cytology
Also called paradoxical Overflow incontinence
incontinence
Pathophysiology of stone Too high solutes to stay
formation dissolved in urine
(supersaturation),
precipitation and
aggregation to form
concretions or stones
Most common cause of uric Dehydration
acid stone
Most common urinary stone Calcium oxalate
Caused by urinary Struvite stones (Proteus
infections with mirabilis is the most
ureaseproducing common)
organisms
Gold standard for stones in Unenhanced helical CT of
the setting of acute flank the abdomen and pelvis
pain
Gold standard for stones in Ultrasound
pregnant women
If CT is not available for KUB radiograph
stones
Size of urinary stone likely <5 mm
to pass spontaneously
Stone size best treated with <3 cm
shock wave lithotripsy
(ESWL)
Stone size best treated with >3 cm
percutaneous
nephrolithotomy (PCNL)
Metabolic factors that Low urine volume
increases formation of Hypercalciuria
stones Hypocitraturia

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SURGERY UROLOGY PART 2 LECTURE 5.3

SUMMARY TABLE
I. OBSTRUCTION AND URINARY STONE DISEASE
• Hydronephrosis is “swelling of kidneys when urine flow is obstructed in any part of the urinary tract.”
• Swelling of the ureter, which can accompany hydronephrosis, is called hydroureter.
• May be seen on CT imaging or ultrasound, may range from very mild to severe, with associated parenchymal thinning in chronic
cases.
• Urinary Stone Disease also known as Urinary Lithiasis.
• One of the most common conditions in Urology
• May affect 10% of the population over the course of a lifetime.
• Stones are crystalline aggregates of one or more components, most commonly calcium oxalate.
Urinary Stone Description
CALCIUM OXALATE • Most Common Type
• Comes in two main forms:
o Dihydrate
o Monohydrate – harder stone, more
difficult to fragment
• Urinary Citrate is a strong inhibitor; prevents crystal
aggregation of calcium stones.
URIC ACID STONES • Most common radiolucent and dissolvable stones
• Dissolution therapy can be done by alkalinizing the urine
to a pH 6.5 to 7.5
• Alkalinizing agents:
o Potassium Citrate
o NaHCO4
• Large uric acid stones may need some intervention to
speed up the dissolution: Shockwave lithotripsy, Laser
lithotripsy
STRUVITE • Also referred to as “infection stones”
• Caused usually by urease-producing organism like
Proteus mirabilis
• Has a tendency to create “staghorn” calculi

CYSTINE • Caused by a homozygous recessive gene for cystine

transport, producing excess urinary cystine.
• Common in pediatric patients
• Cystine stones are the hardest stones, difficult to
fragment.
OBSTRUCTION
• Major sites of renal stone impaction:
• Ureteropelvic Junction
• Crossing of the iliac artery
• Ureterovesical Junction
DIAGNOSTICS
• CT STONOGRAM
• Gold standard is currently the CT stonogram in the acute renal colic setting, in adults and non-pregnant patients.
• ULTRASOUND
• used for pregnant patients.
• CT UROGRAM
• Better modality since it can diagnose other forms of obstruction
• Cannot be used in emergency settings
▪ Need creatinine test first
• Higher radiation exposure compared with CTS
II. HEMATURIA
• Hematuria is defined as the presence of red blood cells in the urine.
• When visible to the patient, it is termed Gross Hematuria which can appear bright red, to pinkish, up to cola or tea colored
• Microscopic hematuria is that detected by the dipstick method or microscopic examination of the urinary sediment. Defined as:
• Dipstick Blood (+) – note that it will also show positive in myoglobinuria & hemolysed Hb
• Microscopy > 3/hpf (flow cytometry) > 5/hpf (light microscopy)

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SURGERY UROLOGY PART 2 LECTURE 5.3

• Hematuria has to be thoroughly evaluated.

• Causes can be from the simplest to the most serious. (ie: UTI to Malignancy)
• Ex: Urinary Tract Infection, Urinary stone disease, Renal or Urothelial cancer.
ETIOLOGY
• Hematuria pts can also be classified as Glomerular or Non-glomerular.
• Glomerular Hematuria, is usually the concern of the Nephrologist.
• Non-Glomerular, is usually the concern of the Urologist, and can be further subdivided into:
▪ Upper tract – kidney & ureter
▪ Lower tract – bladder & urethra
COMMON CAUSES OF GLOMERULAR HEMATURIA COMMON CAUSES OF NON-GLOMERULAR HEMATURIA
• IgA nephropathy (Berger’s disease) Upper Tract Lower Tract
• Thin glomerular basement membrane disease ▪ Urolithiasis ▪ Bacterial cystitis (UTI)
• Hereditary nephritis (Alport’s syndrome) ▪ Pyelonephritis ▪ Benign prostatic
▪ Renal cell cancer hyperplasia
▪ Transitional cell ▪ Strenuous exercise
carcinoma (“marathon runner’s
▪ Urinary obstruction hematuria”)
▪ Benign hematuria ▪ Transitional cell carcinoma
▪ Spurious hematuria (e.g.
menses)
▪ Instrumentation
▪ Benign hematuria
HEMATURIA RISK FACTORS HEMATURIA EVALUATION
• Hematuria pts should be classified as Low or High Risk • Pts are considered High Risk if with gross hematuria
• High Risk Factors: and/or any of the High Risk factors
• Age >40 years • Pts are considered low risk if with Asymptomatic
• Male gender Microscopic Hematuria with none of the High Risk
• Hx of cigarette smoking factors.
• Hx of chemical exposure • Succeeding evaluation depends on the risk
• Hx of pelvic radiation stratification
• Irritative voiding Sx (urgency, frequency, dysuria) • For Low Risk:
• Prior urologic disease or treatment o Renal ultrasonography
• 10% chance of documenting a malignancy in pts with ▪ Masses, nephrolithiasis,
asymptomatic microhematuria hydronephrosis
o Regular follow-up with:
▪ Urinalysis and renal ultrasonography
• For High Risk:
o Contrast-enhanced imaging of the kidneys and
ureters (CT Whole Abdomen or CT Urogram)
o Urine cytology.
o Cystourethroscopy
▪ Imaging &/or cytology is
suspicious for ureteral pathology, Retrogade
Ureterograms &/or Ureteroscopy is done along
with the cystourethroscopy Bladder &/or
Ureteral Barbottage (or wash”) is done, and
sent for cytology
III. UROLITHELIAL AND BLADDER CANCER
• They have both same pathology and both are Transitional Cell Carcinoma. They just differ in location.
• Urothelial Cancer - cancers in the urinary tract starting urothelial cells to the renal pelvis to the ureters.
o 80-90% present with gross hematuria
o Some would have irritating voiding symptoms (frequency, urgency, nocturia)
• Bladder Cancer- when the cancer goes to the bladder.
• They are the 2nd most common urologic malignancy

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SURGERY UROLOGY PART 2 LECTURE 5.3

BLADDER SQUAMOUS CELL CARCINOMA CLINICAL STAGING OF BLADDER CANCER

• CT/MRI – to assess intraabdominal nodal and visceral sites of
• Usual Etiology: Chronic irritation from catheters, bladder metastasis.
stones etc.
• CT urography or retrograde pyelography- to evaluate upper tracts
• Another unique kind of bladder squamous cell carcinoma
• Chest radiograph- initial evaluation of thorax and mediastinum
which comes from Schistosomiasis hematobium.
• Bone scan- if patient complains of bone pain, has known locally
advance or metastatic disease or unexplained elevation of ALP.

STAGING OF PELVIC LYMPH NODES MANAGEMENT

• NX- regional lymph nodes cannot be assessed due to lack • Trans-urethral Resection of the Bladder Tumor (TURBT)
of information. o Is actually both diagnostic and therapeutic
• N0 – No regional lymph node spread. o This is for superficial bladder tumor(T1), TURBT can be
• N1- The cancer has spread into single lymph node in the curative. However, there is still a need to do intravesical
true pelvis. chemotherapy.
• N2- The cancer has spread to 2+ nodes in the true pelvis. • T1- (Non- invasive) disease
• N3- The cancer has spread into the lymph nodes that lie o Can be managed by TURBT alone
along the common iliac artery. o Patients with HIGH GRADE tumor or Recurrent disease
may benefit from Intra-vesical Chemotherapy.
STAGING OF DISTANT METASTASIS o BCG (Bacilli-Calmette-Guerin)
• M0- No signs of distant spread. o Mitomycin C
• M1: The cancer has spread to distant lymph nodes, organs, o Docetaxel
tissues (like the bones, lungs, or liver)
• Invasive bladder CA
o T2+, where the tumor invades the muscularis, removal of the
part of the entire bladder becomes necessary.
o Partial Cystectomy – for invasive but solitary tumors that involve
the dome of the bladder(T1-2).
o Radical Cystectomy- men, radical cystoprostatectomy where the
bladder and prostate are removed en bloc.
o Anterior Pelvic Excenteration- women, where the bladder,
uterus and ovaries are removed en bloc.

COMPLICATIONS OF BLADDER SURGERY

o TURBT – bladder perforation
o Cystectomy and urinary diversion – prolonged ileus, bowel obstruction, intestinal anatomical leak, urine leak or rectal injury.
o Cystectomy- deep venous thrombosis

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 SURGERY UROLOGY PART 2 LECTURE 5.3

APPENDIX

Figure 1. Acute Renal Colic Management Algorithn

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