POCKET GUIDE

for the
INTERN & MEDICAL STUDENT
Table of contents

Welcome 4
Description of urology clinical service 4
Sub-intern goals and responsibilities 5-7
Intern goals and responsibilities 8-9
Overview of residency 10
Research at MGH Department of Urology 11-12
Basic concepts in urology
Urologic emergencies
Genitourinary trauma 13-17
Priapism 18-20
Fournier’s gangrene 21-22
General Urology
Urinary retention 23-27
Acute Renal Colic 28-29
Erectile dysfunction 30-32
Benign prostatic hyperplasia (BPH) 33-35
Evaluation of scrotal masses 36-37
Urinary tract infection 38-40
Urologic Oncology
Renal Cell Carcinoma & Renal Cysts 41-44
Upper Tract Urothelial Carcinoma 45-47
Bladder Cancer 48-51
Prostate Cancer 52-56
Procedures

Updated 6/2018 2
 Foley catheter placement/Bladder irrigation 57-61
Bedside cystoscopy 62-63
Priapism – Corporal Irrigation 64

Updated 6/2018 3
Welcome

Dear sub-intern/intern,

We are proud to welcome you to the MGH department of urology. This is a very exciting
time in your career and finding a residency that fits you is of utmost importance. The goal of
our residency is to train you to be the best urologic surgeon you can be, and expose you to all
aspects of urology. In addition, we hope to provide opportunities to help develop your interests
and take full advantage of the opportunities for collaboration that come along with training in
the city of Boston.

In this guide you will find an introduction to our department and to provide you with
basic information that you might find useful during your initial arrival at MGH. More specific to
our interns, we provide you a list of the faculty’s research interests and guidelines for choosing
a mentor and project as you progress through your intern year.

Michael L. Blute, MD
Chairman

Ajay Singla, MD
Residency Program Director

Description of urology clinical service

The current clinical service is divided into four separate teams (Leadbetter, O’neil, Kerr
and Fellow). Average daily patient census is 6-8 patients per service. Each service has a junior
resident, chief resident, and occasionally an intermediate resident. We have two wonderful
PAs, Rachel Perez and Emily Mulla. They will help to cover the O’neill, Kerr and Fellow services
while junior residents are in the operating room. The intern usually spends time on Leadbetter
during which he/she will carry the emergency department consult pager and cover the patients
on that service. Sub-interns will rotate through each of the teams (1 week on each team) at the
discretion of the chief residents.

Updated 6/2018 4
Sub-intern rotation details

Accommodations

Please make plans for accommodations early since it can be challenging to find a place close to
MGH. If you have any questions or have difficulty obtaining a place to stay please contact Kim
Williams (kwilliams40@partners.org) and she well put you in touch with a resident who may be
able to assist you. Consider proximity to the public transportation when choosing a place to
stay.

Useful websites:

http://boston.craigslist.org/

http://www.massgeneral.org/mao/resources/housing.aspx http://rotatingroom.com/

- sublet website for medical students, by medical students.

Please be advised that these listings are provided simply as a convenience to students and that
we do not officially endorse these establishments. Arrangements are made independently
between the establishment and the student.

Public transportation

Boston is a city with excellent public transportation. Please check the MBTA website
(http://www.mbta.com/) for up to date information. Please note the earliest times that the T
opens to properly plan your arrival for rounds during your rotation.

Identification cards

The ID office is located on the second floor of the Wang building. When you exit the
elevators make a right and follow the signs to the MGH security office. There you will be able to
get your picture ID.

Important locations

Urology resident call room – located in the White building on the 8th floor. This is where you will
go to meet up with residents throughout the day.

Urology offices – Currently split between Wang 528 and Ruth Sleeper Hall. Dr. Blute, Dr. Singla
and Kim Williams have offices in Ruth Sleeper Hall 1st floor at 40 Parkman Street.

Updated 6/2018 5
Urology Clinic – CPZ 7, 165 Cambridge Street, 7th floor. Nearly all of the faculty have clinic in this
space. It is a newly renovated space with a large number of patient rooms, offices and
procedural rooms.

Emergency department – located on the first floor close to the Fruit street entrance to the
hospital. As a sub-intern you are encouraged to follow the intern/residents to see consults in
the emergency department to get an idea of the breadth of consults that we have the
opportunity to see at MGH as a result of being a large tertiary and level 1-trauma center.

Cafeteria – located in the basement. There is also a coffee shop outside of the Gray/Bigelow
elevators on the first floor and a small cafeteria on the basement floor of the Wang building.

Computers – if there are no available computers in the urology call room you can use the
resident lounge on the first floor of the Wang building.

Computer access/Online resources

After obtaining computer access, please double check that you have access to EPIC. You
will use this program to access patient clinical information, operating room schedules, and to
help print patient lists for rounds, respectively. If you do not have access to EPIC, please email
Cindy Murphy (CMURPHY3@mgh.harvard.edu).

Meeting with Chief resident

Each sub-intern should meet with one of the three chief residents during the first few
days of the rotation to discuss goals and responsibilities for the month.

Team-work

Sub-interns are expected to work together as a team with their co-residents and
medical students. We expect that you will try to incorporate yourself into the team and really
try to experience what it may be like to be an MGH resident. Your focus should be on trying to
follow your patients throughout the rotation. At times there may be up to four other medical
students on service. Make sure that you are working together to assign each other cases in a
way that will allow you to obtain a grasp of the different procedures performed at MGH, but
also give you an opportunity to get to know the faculty. It would be beneficial to stay with one
preceptorship based team for a pre-determined amount of time.

Pre-rounding/rounding

Touch base with the junior resident on your team to find out exact details about how to
pre-round and other tasks that may be helpful in the morning. Rounds usually start at 6 AM,
but may be earlier if there are conferences scheduled that morning or the team has a
particularly large census (important to take into account when choosing your
accommodations). Try to pre-round on the patients whom you have seen in the OR and
examine them before rounds. It will be up to your team chief, but you should try to come up

Updated 6/2018 6
with an assessment and plan for your patient to be presented during rounds. Help follow-up on
tasks during the day that may be helpful to other team members.

Operating room

The first day of the rotation make sure to take the scrub class so that you are able to
scrub into cases. Once you are done with your scrub class please report to the urology office
where Cindy Murphy will give you the information about who to report to next.

The operating room schedule will be emailed the night before the OR day. Please make
sure to discuss which cases you will be scrubbing in on with your fellow medical students. In
general, try to spend the day with one attending rather than trying to bounce around different
rooms. This will give you an opportunity to get to know the faculty in the department.

You should have access to the patient’s medical record including clinic visits, imaging,
and pathology. Make sure you come prepared to discuss the patient’s presentation, physical
exam findings, and indication for the procedure. In addition, be ready to discuss relevant
anatomy for the procedure. You have access to Campbell’s urology through the MGH Treadwell
library (http://www2.massgeneral.org/library/ -> ebooks -> search for Campbell’s urology -> log
in with partners username and password). Alternatively, in EPIC you have a tab that is called
“handbook” which contains links to pubmed, ebooks, and UptoDate for your review.

Clinic

During your rotation try to spend at least one afternoon per week in clinic to get a sense
for what office urology is like (schedule included in the appendix). This will be another way for
you to get to know the faculty in the department.

Presentation

Medical students who are applying to urology residency programs are required to give a
10-minute presentation (8 minutes plus 2 minutes for questions) on a topic of their choice.
Residents should try to identify a topic early on in the rotation and ask the chief residents for
guidance on the specific topic. This should be a focused presentation with a thorough literature
review. Students should be able to show mastery in the specific area and try to avoid
presenting summaries of chapters in Campbell’s. Furthermore, try to stay away from choosing
topics that are currently controversial in the field and/or do not have a clear consensus.

Letters of recommendation

Students should try to schedule a meeting with Dr. Blute (please email Cindy Murphy at
cmurphy3@mgh.harvard.edu) towards the end of their rotation to discuss the departmental
letter of recommendation. Letters will be a compilation of comments received from residents,
faculty, and assessment of your presentation. Please bring a copy of an up to date CV to your
meeting with Dr. Blute.

Updated 6/2018 7
Intern goals and responsibilities

Schedule

You will have a total of 3 months of urology during your intern year. Your schedule will
usually be Monday through Saturday. During your general surgery rotation you will rotate
through surgical oncology, pediatric surgery, SICU, trauma surgery, and general surgery.

Objectives

The objectives of the urology intern rotation:

1. Become familiar with the management of post-operative urologic patients

2. Understand the management of common emergent urological consults
3. Become facile in the placement of difficulty Foley catheters and bladder irrigation
4. Learn the basics of endoscopy in the operating room

Team-work

The intern will usually start on the Leadbetter service as the responding clinician and
hold the emergency department consult pager (see details below). The urology intern job
comes with great responsibility as you will be the first one assessing patients in the emergency
department and in charge of triaging these patients. If our PAs are off, the intern will often
assist in covering the list of the post-call resident.

Knowledge

Dr. Singla will be providing you (the Urology categorical interns) with a copy of Smith’s
Urology that you should read in completion during your intern year. In preparation for the
inservice we will have a mock 25-question exam after intern year and 50-question exam after
your first year of urology.

Consults

The intern usually holds the consult pager that is usually used to call intra-operative,
emergency department, and occasionally floor consults.

• Intra-operative – you will at times be called directly from the operating room for an
intra-operative consult. This will range from a difficulty Foley placement to
assistance with a potential bladder and/or ureteral injury. If it is the latter, try to get
as much information about their primary concern, patient name/MRN, and
immediately contact the proper attending with the details of the consult. For the

Updated 6/2018 8
 former, ask about what catheters have been tried. Prior to going to the operating
room make sure to take a thorough look through the patient’s history, labs, and
prior imaging to look for a history of BPH, urethral stricture disease, and/or prior
urologic surgery. Many patient’s that we get consulted for have been seen in the
past by Urology.
• Emergency department – the most common emergent consults include symptomatic
nephrolithiasis (pain +/- infection) – of which patients may present with urosepsis,
urinary retention, epididymoorchitis, Fournier’s gangrene, priapism, and hematuria.
Please make sure to read about these conditions prior to the start of your rotation.
• Floor/Inpatient – the consult resident will usually take care of the floor consults, but
you will occasionally be called to assist with difficult Foley placements and to assist
with bladder irrigations in patients with clot retention. During the weekends you will
be in charge of taking all consults with the assistance of the on-call junior resident.

Operating room

During your urology rotation you should become familiar with the instruments used for
cystoscopy and basics of common endourologic procedures. There is not typically an obligation
to be in the OR, but it is beneficial to you to get as much exposure to basic urologic cases as
early as possible.

Mentorship

Dr. Singla will meet with you within the first couple of months of your intern year to
assign you a mentor in the department of urology. During your intern year, start thinking about
a potential area of interest and projects for research.

Resources

1. Treadwell Library (http://www2.massgeneral.org/library/default.asp)

a. Many electronic textbooks, journals & other online resources are available
b. Can access from internal or external computers via Partners username/password
2. Textbooks
a. Campbell-Walsh Urology, 11th Edition; Authors: Alan J. Wein & Louis R. Kavoussi & Alan
W. Partin & Craig A. Peters
i. Considered the preeminent textbook of urology. While comprehensive,
this textbook may be too exhaustive for general use of interns and
medical students.

b. Wieder's Pocket Guide to Urology Spiral-bound – 2014, 5th Edition

i. An excellent resource for quick reference.

Updated 6/2018 9
Overview of residency

The MGH residency provides trainees a strong clinical exposure to general urology,
urologic oncology, stone disease, infertility, voiding dysfunction, female urology, and pediatric
urology. Residents have the opportunity to rotate through Children’s Hospital Boston during
their junior years. Laparoscopic and robotic skills are solidified during the later years of training.

All urology interns have the same general surgery and urology rotations. All Urology
residents begin URO-1 year at the same time. The Urology residents move through various 4
month rotations for a duration of 2 years. After the URO-2 year, all URO-3 residents enter
research at the same time. One resident will perform 4 months of research, one performs 8
months and one performs 12 months. It is the responsibility of the residents to decide the
research duration. After completing research, residents will return to MGH to complete the
senior/chief year rotations.

At the end of residency trainees remain on staff as the “Cabot attending” during which
he/she will have attending privileges at MGH and be in charge of their own clinic, overseeing
the resident clinic, and take call for trauma at a level 1 trauma center. This unique experience
allows residents to work as attendings under the continued guidance of the MGH faculty.

Conference curriculum

Tuesday morning resident conferences

Residents take turns leading weekly discussions of a particular topic in urology. Each
session is led by a faculty member with particular expertise in the topic presented.

Thursday morning indications and grand rounds

Every Thursday morning at 7 AM residents meet to discuss cases scheduled through the
urology resident clinic and staffed with the Cabot attending. Grand rounds usually runs from
7:30 to 9:30 AM where we have lectures from faculty within the department of urology, other
MGH departments, resident case presentations, or GU oncology conferences.

Oncology fellowship

There are two fellows per year in the combined Brigham and Women’s Hospital/MGH
urologic oncology fellowship. The fellows rotate through both hospitals and are a tremendous
asset to resident education and training. Fellows are also keen to involve residents in ongoing
research. The fellows

Updated 6/2018 10
Research at MGH Department of Urology

Kidney Cancer

a. A comparison of nephron sparing techniques: percutaneous radiofrequency ablation

(RFA) vs. open and laparoscopic partial nephrectomy (Feldman)
b. Renal Biopsy for suspicious renal masses: The MGH cohort of 1000 patients (Feldman)
c. Molecular pathogenesis of angiomyolipoma and other TSC related neoplasms (Wu –
funded by NIH/Program Project)

Bladder Cancer
a. Multi-institutional bladder cancer quality care initiative for non-metastatic muscle
invasive transitional cell carcinoma of the bladder (Feldman)
b. RTOG 0926: Phase II – Management of aggressive forms of stage T1 bladder cancer with
trimodality therapy (TURBT, chemotherapy, and radiation) (Dahl)
c. RTOG 0524: Paclitaxel and radiation therapy with or without Trastuzumab in treating
patients who have undergone surgery for bladder cancer (Dahl)
d. Genetic signatures in T1 G3 bladder cancer (McDougal)

Prostate Cancer

a. 5-alpha reductase 2 expression in adult prostate tissue (Olumi – funded by NIH/R01)

b. Biomarkers for active surveillance in prostate cancer (Feldman – funded by DOD &
Prostate Cancer Foundation)
c. Circulating tumor cell (CTC) analysis in prostate cancer (Dahl)
d. Molecular mechanisms of resistance to pro-apoptotic therapies (Olumi – funded by New
York Academy of Medicine)
e. Metabolic state of prostate cancer cells determines sensitivity to Metformin in prostate
cancer cells (Olumi)
f. Genetic signatures in prostate cancer (McDougal & Wu)
g. Template biopsy in patients who are highly suspicious for having prostate cancer but
have had negative biopsies (McDougal)
h. Metabolomics of prostate cancer in prostate biopsy specimens (McDougal & Wu –
funded by NIH)

Updated 6/2018 11
Penile Cancer

a. Penile conserving surgery for penile cancer (McDougal)

Infertility
a. Sperm vitrification (Tanrikut)
b. Clinical outcomes related to testosterone replacement therapy (Tanrikut)
c. Dietary impacts on semen parameters (Tanrikut)

Nephrolithiasis
a. Analysis of 24-hour urines and risk factors for recurrent nephrolithiasis (Eisner)
b. Use of paravertebral nerve block in patients undergoing percutaneous nephrolithototmy
(Eisner)
c. Predictive factors and stone characteristics for patients evaluated in the emergency
department with flank pain (Eisner)
d. Novel MRI applications for the detection of renal stones (Eisner)

Tissue Biobank (Wu & McDougal – Funded by MGH Bertucci Research Fund)

a. Prostate: 3547
b. Kidney: 1091
c. Bladder: 244
d. Testis: 140
e. Adrenal: 221

Updated 6/2018 12
UROLOGIC EMERGENCIES

Genitourinary Trauma Tim Brown, MD,PhD

• Indications for genitourinary (GU) evaluation in a trauma patient:

o Traumatic hematuria o Gross hematuria o Penetrating trauma
o Pediatric patient and any degree of hematuria
o Blunt trauma with microscopic hematuria and shock
• Indications for evaluation of GU trauma in the absence of hematuria:
o Mechanism of injury: rapid deceleration or flank injury
o Clinical findings (mechanism of injury): flank ecchymosis, flank pain,
posterior rib fractures, transverse process fractures near kidney, pelvic
fracture, etc Radiologic studies:
o Abodomen/pelvis CT with delays: suspected renal/ureteral injury o CT-
cystogram: suspected bladder injury
o RUG (retrograde urethrogram): suspected urethral injury o Scrotal
ultrasound: testicular injury

Renal trauma

• Facts o Most common GU organ injured by trauma o Blunt trauma

accounts for > 90% of renal injuries
o Children are more susceptible to renal trauma due to less perirenal fat,
underdeveloped rib cage and less muscle
• Evaluation o Imaging study of choice: 2-phase contrast renal CT
▪ Vascular/cortical phase 30 seconds after IV contrast
▪ Delayed phase 10 minutes later to assess for perirenal or ureteral extravasation
o IVP and Ultrasound are low yield and less reliable
▪ Single shot IVP can be used in unstable patient in the OR to confirm
presence of a contralateral kidney
• Classification o Grade 1: contusion or subcapsular hematoma o
Grade 2: cortical laceration <1cm, no extravasation o Grade 3:
cortical laceration >1cm, no extravasation
o Grade 4: laceration >1 cm deep into collecting system OR vascular injury
(thrombosed renal artery or segmental vein injury) o
Grade 5: shattered kidney OR renal pedicle avulsion
• Management

Updated 6/2018 13
 o Initial observation is appropriate for patient with renal parenchymal injury and
urinary extravasation
o The only absolute indication for renal exploration is hemodynamic instability
from renal injury (should avoid unnecessary exploration due to risk of releasing
perirenal tamponade)
o Urinary drainage via ureteral stent should be performed in the presence of an
enlarging urinoma, fever, increasing pain, ileus, fistula or infection. May need to
augment with percutaneous drain, percutaneous nephrostomy or both.
Ureteral trauma

• Facts o Iatrogenic trauma is most common cause of ureteral injury

(during abdominal, pelvic, retroperitoneal or endoscopic surgery)
o Most non-iatrogenic injuries are due to penetrating trauma
• Evaluation o Diagnosis can be challenging- hematuria and
retroperitoneal (RP) hematoma are absent in ~ 1/3 of cases
o Must have high index of suspicion:
▪ Clinical scenarios (penetrating wounds in proximity to the ureter, sudden
deceleration injury, especially in children, and recent surgery in
proximity to ureter)
▪ Symptoms (flank abdominal pain, flank mass, prolonged ileus, upper
urinary tract obstruction or hydronephrosis, elevated BUN/creatinine,
high surgical drain output)
• Evaluation o CT with delayed imaging- likely to reveal urinary
extravasation
▪ Retrograde pyelogram- most accurate imaging test (utilize when CT is
inconclusive)
▪ Direct inspection during laparoscopy is ideal if ureteral injury is suspected
▪ May utilize dyes (methylene blue or indigo carmine) in antegrade or
retrograde fashion to identify ureteral injuries
• Principles of Repair o Diagnosis within 5 days, consider immediate
repair
o >/= 5 days, sepsis or debilitated patient, drain urinoma percutaneously, place
nephrostomy and/or ureteral stent and repair electively
o Okay to repair in presence of bowel injury, fecal contamination and vascular
injury- utilize tissue interposition when possible (e.g. omental flap)
o Okay to repair ureteral injuries during vascular graft surgery if urine is sterile
o Repair over stent and leave retroperitoneal drain o Post operative management:
▪ Leave urethral catheter ~ 24-48 hours and then remove
▪ Remove retroperitoneal drain 24 hours after urethral catheter if output
remains minimal

Updated 6/2018 14
 ▪ Remove stent in 4-6 weeks
▪ Follow imaging (CT urogram or renal scan) 4-8 weeks after stent removal
• Types of Repair o Ureteral reimplant (ureteroneocystostomy) +/-
psoas hitch +/- Boari flap
▪ Preferred repair for ureteral injuries below iliacs and most extensive
mid and distal injuries o Ureteroureterostomy
▪ Preferred repair for abdominal ureteral injury with short defect (< 1 cm)
o Ileal interposition
▪ For use when long segment of ureter is damaged o Autotransplant
o Other repairs: transureteroureterostomy, ureteropyelostomy,
ureterocalycostomy

Bladder trauma

• Facts o Typically seen with pelvic fracture or blunt trauma with distended bladder
o Occurs in 6-10% of pelvic fracture cases
• Evaluation o Suspect with gross hematuria, pelvic fracture, suprapubic
tenderness, MVA o Intraperitoneal bladder rupture may present in delayed
fashion with ileus/urinary ascites/elevated BUN/Cr or no return of urine with
catheter placement
o Cystogram - must fill to capacity ( >350 cc) and obtain drainage films (or do CT
cystogram)
• Management
o Extraperitoneal bladder rupture: catheter drainage alone
o Exceptions requiring repair: bone fragment in bladder, open pelvic fracture,
rectal perforation, bladder neck injury, pt undergoing internal fixation of pelvis
o Intraperitoneal bladder rupture: immediate operative repair
▪ Technique: open bladder and close in 2-3 layers o Follow up:
cystogram 10-14 days after repair prior to catheter removal

Urethral trauma

• Facts o Rare in females (< 2%) or without pelvic fracture o Associated with bladder
rupture in 10-17%
o Anterior urethral injuries (distal to membranous urethra, i.e. bulbar, penile and
glandular urethra)
▪ Usually caused by blunt trauma (straddle injury) or penetrating injury
(stab or gunshot)
▪ 10% of all urethral injuries
o Posterior urethral injuries (membranous to bladder, i.e. membranous and
prostatic urethra)

Updated 6/2018 15
 ▪ Almost all are from pelvic fracture from blunt trauma

• Evaluation o Suspect with blood at meatus, high-riding prostate,

penile/scrotal/perineal hematoma, pubic ramus fracture, difficulty voiding and
distended bladder
▪ Eggplant deformity: anterior urethral injury where blood is contained by
Buck’s fascia
▪ Butterfly hematoma: seen with straddle injury where Buck’s fascia is
ruptured and hematoma is contained by Colles’ fascia
o All suspected urethral injuries warrant a retrograde urethrogram (RUG)
• Management
o Posterior urethra injuries
▪ Immediate repair: only recommended when there is a concomitant
rectal or bladder neck injury (immediate repair has higher rates of
incontinence and impotence)
▪ Delayed repair: initially treat with bladder drainage (SPT vs urethral
catheter) followed by repair in 3-6 months
▪ Primary endoscopic realignment is preferable (50% heal without
significant urethral stenosis)
▪ Methods of placing urethral catheter
• Blind passage of Foley by urologist
• Bedside flexible cystoscopy
• To OR for rigid cystoscopy and/or antegrade flexible cystoscopy through SPT site
o Anterior urethral injuries
▪ Typically managed by bladder drainage by SPT or Foley and deferred repair
if necessary

Penile trauma

• Gunshot and penetrating injuries o Immediate exploration, copious irrigation, excision

of foreign matter, antibiotic prophylaxis and surgical closure
o Strongly consider retrograde urethrography
▪ Repair urethral injuries primarily
• Amputation o Reimplant if possible
o Preserve amputated penis in wet sterile gauze in baggy placed on ice o <24 hour
cold ischemia time to be viable (~16 hours or 6 hours warm ischemia)
• Fracture o Rupture of tunica albuginea of erect penis typically sustained during
intercourse o Requires immediate surgical repair
o Associated urethral injury in 10-20% of cases: must assess with RUG vs flexible
cystoscopy in the OR in suspected cases (hematuria, inability to void)

Updated 6/2018 16
Testicular trauma

• Facts o Most cases secondary to blunt trauma from athletic activity

• Evaluation o Ultrasound - can be useful but should not dissuade exploration if physical
exam demonstrates significant testicular trauma
▪ Should not delay immediate exploration o Physical exam and
ultrasound cannot reliably distinguish intratesticular hematoma from
testicular rupture (tear in tunica albuginea)
▪ Therefore surgical exploration is recommended for either
• Management
o Prompt surgical repair
o 80-90% of testicles are salvaged with surgery within 72 hours of injury vs. 3245%
when surgery is delayed beyond 72 hours.

Updated 6/2018 17
Priapism Dayron Rodriguez, MD, MPH and Michael T. Grant, MD

Definition: Priapism is a persistent penile erection that continues hours beyond, or is unrelated
to, sexual stimulation and lasts greater than four hours duration.

Ischemic vs. Stuttering vs. Non-ischemic Types

• Ischemic (veno-occlusive, low flow) priapism - caused by decreased venous outflow

which causes increased intracavernosal pressure which leads to a non-sexual, persistent
erection with decreased arterial inflow, stasis of blood local hypoxia and local acidosis.
It is characterized by abnormal cavernous blood gases (hypoxic, hypercarbic, and
acidotic). The corpora cavernosa are rigid and tender to palpation, but the glands and
corpus spongiosum ar soft. Patients typically report pain. A variety of etiologic factors
may contribute to the failure of the detumescence mechanism in this condition which
include: sickle cell trait and disease, malignant infiltration of the corpora, TPN,
medications such as anticoagulants, antihypertensives, antidepressants (trazadone),
alpha blockers, methylphenidate , cocaine, treatments for erectile dysfunction,
hyperosmolar IV contrast, spinal cord inhury and spinal or general anesthesia. Ischemic
priapism is an emergency and requires immediate treatment.
• Stuttering (intermittent) priapism - a recurrent form of ischemic priapism in which
unwanted painful erections occur repeatedly with intervening periods of detumescence
(not rapid recurrence of a single episode). This historical term identifies a patient whose
pattern of recurrent ischemic priapism encourages the clinician to seek options for
prevention of future episodes. Prevention strategies include the use of LHRH agonists
with an anti-androgen to prevent testosterone flare, or the intracavernosal injection of
phenylephrine in men who fail or decline hormone therapy.
• Nonischemic (arterial, high flow) priapism - caused by increased arterial inflow without
decreased venous outflow, resulting in high inflow and high outflow producing a
prolonged, non-painful partially rigid erection (corpora cavernosa) without local hypoxia
or acidosis. The most common cause is perineal or penile trauma that causes a fistula
between the cavernous artery and the corporal tissue. Doppler U/S can identify a
cavernosal artery fistula, however arteriogram is the gold standard for diagnosis.
Treatment is not an emergency.

Evaluation/Work-Up
The most important task is to differentiate ischemic from non-ischemic priapism!!!
• History - duration of erection, degree of pain (ischemic priapism is painful while
nonischemic priapism usually is not), previous history of priapism and its treatment, use
of drugs that might have precipitated the episode, drugs that have been associated with

Updated 6/2018 18
 priapism , history of pelvic, genital or perineal trauma, history of sickle cell disease or
other hematologic abnormality.
• Examination - The genitalia, perineum and abdomen should be carefully examined. In
ischemic priapism, the corpora cavernosa are often completely rigid, while in
nonischemic priapism, the corpora are typically tumescent but may not be completely
rigid. Abdominal, pelvic and perineal examination may reveal evidence of trauma or
malignancy.
• Labs/Imaging - CBC, reticulocyte count, hemoglobin electrophoresis, urine toxicology,
cavernosal blood gas, color duplex ultrasonography, penile arteriography.
Cavernosal Blood Gas
Doppler Ultrasound
PO2 PCO2 pH Cavernousal Artery & Blood Flow Velocity

Ischemic Priapism < 30 > 60 < 7.25 Zero or Minimal

Non-Ischemic > 90 < 40 7.40 Normal or High

Priapism*

Normal flaccid penis++ 40 50 7.35 -

* Similar to normal arterial blood ++ Similar to normal mixed venous blood

Management (based on AUA guideline panel)

Updated 6/2018 19
* After intra-cavernosal phenylephrine monitor blood pressure and pulse. Cardiac patients
should be placed on telemetry
* Resolution of priapism may be confirmed by repeat cavernosal blood gas or Doppler U/S.

• Corporal Aspiration and Irrigation (see instructions below) Distal shunts:

o Winter: Tru-cut biopsy needle (multiple cores) between distal corpora cavernosa
and glans. o Ebbehoj: stab incision on glans and rotation of blade between distal
corpora cavernosa and glans
o Al-Ghorab: 2 cm transverse incision and excision of tunica albuginea from each
corpus
• Proximal shunts:
o Quackel: corporal- spongiosum shunt o Grayhack: corporal-saphenous shunt

*** Proximal shunts have a higher rate of erectile dysfunction than distal shunts.

Other points
• Oral systemic therapies, such as pseudoephedrine, are not recommended by the AUA
guidelines. Prostate massage, ice packs to penis and enemas are not effective and not
recommended by AUA guidelines.
• The longer the priapism duration, the higher the rate of impotence. 90% of men with
priapism > 24 hours develop severe erectile dysfunction. Even with early intervention
impotence occurs in up to 50% of patients.
****Instructions for Corporal Irrigation can be found on page 59.

Updated 6/2018 20
Fournier’s Gangrene Monica Velasquez, MD

• Potentially life-threatening form of necrotizing fasciitis involving the (generally male)

genitalia.
• Originally reported in 1784 by Baurienne, characterized by Fournier in 1883.
• 95% of cases now have an identifiable source o Most commonly from skin, urethra,
urine, or rectum
o Predisposing factors: DM, liver dysfunction, or other immunocompromised
state, local trauma, instrumentation (catheter or GU surgery,) paraphimosis,
perirectal/perianal infections or fissures, groin/genital surgery (circumcision,
herniorraphy.)
o Wound cultures typically multibacterial with both aerobes and anaerobes o
Infecting bacteria may pass through Buck’s fascia, spread along the dartos of
scrotum/penis -->may end up involving or spreading to Colles fascia of perineum
and Scarpa of anterior abdominal wall. (This is why you must debride widely!)

Diagnosis
• Diagnosis is clinical
• Early stages: involved area is swollen, erythematous, and tender; crepitus is an early
finding but in early stages can be subtle.
• Late stages: fever, discoloration and necrosis, bullae formation, skin anesthesia over
areas of deep pain, marked systemic toxicity out of proportion to local exam
• Labs: Leukocytosis OR leukopenia; elevated creatinine, elevated LFTs, hyponatremia,
hypocalcemia (may be secondary to release of free fatty acids from bacterial lipases that
destroy triglycerides.)
• Radiology: plain film of scrotum/abdomen, ultrasound of scrotum, may be able to
identify air; CT scan more sensitive and specific for extent of air spread along fascial
planes (remember that the overlying skin over affected fascia may appear normal.)

Management
• Surgical and emergent! These patients can decompensate very quickly.
• Diagnosis made on clinical basis—imaging may not be necessary in some situations.
• Broad-spectrum antibiotic coverage against gram positives and gram negatives (can
consider double anaerobe coverage, eg Clindamycin/Flagyl/Zosyn, etc.)
• Extensive debridement, culture, and excision of fascia, subcutaneous tissue, and fat
beyond the area of involvement until normal fascia is found (bleeding.)
• May require suprapubic diversion in cases of urethral trauma/urine extravasation
• May require colostomy in cases of colonic/rectal perforation
• May require amputation at level of hip in case of groin and thigh spread—we’ve seen
this twice in the past few years.

Updated 6/2018 21
 • Wounds are left open with wet-to-dry or with VAC placement; generally not closed
primarily at initial surgery. Second procedure 24-28 hrs later to assess adequacy of initial
debridement, further debridement.
• Orchiectomy almost never required: testes have their own blood supply independent of
fascia and skin of scrotum. Possible exception: when source is epididymitis/orchitis.
• In long-term often require flap or graft closure of initial debridement.

Outcomes
• Mortality in early studies approximately 20%, ranging from 7%-20%.
• Higher mortality in diabetics, alcoholics, colorectal sources of infection, delay in
diagnosis and management.

Updated 6/2018 22
GENERAL UROLOGY

Urinary retention Anton Wintner, MD

Acute vs. Chronic – the failure of the bladder to empty is the result of decreased bladder
contractility (duration and magnitude), increased bladder outlet resistance or both.
Urinary retention may be acute (failure to void with build up of urine in the bladder
causing increasing discomfort) or chronic (elevated post void residual which can
predispose the patient to complications such as bladder stones or urinary tract infection.

Etiology
▪ Because of the Bladder
o Neurogenic
o Myogenic
o Psychogenic
o Idiopathic
▪ Because of the Outlet
o Anatomic
▪ Prostate Obstruction
▪ Bladder neck contracture
▪ Urethral stricture in male
▪ Urethral compression (organ prolapse)/fibrosis in the female
▪ Functional
o Smooth sphincter dyssynergia
o Striated sphincter dyssynergia
o Combination

Evaluation
• History may provide a clue into the cause the patient’s urinary retention. Common
symptoms include hesitancy, straining to void, poor stream, dribbling or overflow
incontinence.
• Vital sign abnormalities such as elevated blood pressure or tachycardia may result from
acute distention of the bladder and in certain patients may be the first sign of acute
urinary retention.
• A focused physical exam should be conducted in cases where there is concern for
urinary retention should include of the following:

Updated 6/2018 23
 o Lower abdomen - bladder distention should be noted. The abdomen may have
old scars indicative of prior surgery. An obstructing abdominal mass may be
palpable.
o Flanks - CVA tenderness may indicate hydronephrosis or infection
(pyelonephritis)
o Genitalia - phimosis, penile mass or urethral stones may be noted. Blood at the
meatus may indicate hematuria with resultant clot obstruction.
o Rectum - decreased sphincter tone may indicate a spinal cord injury or
compression that can also affect bladder contractility. In males the prostate
should be evaluated for evidence of enlargement.

o Pelvic Exam- in females a pelvic exam should be done to rule out an adnexal
mass and pelvic organ prolapse.

o Neurologic and mental status exam - a basic neurologic exam may unveil
neurologic defecits which may also affect bladder function.

Common Predisposing Factors

• Spinal cord injury/spinal shock - spinal shock may result in suppression of somatic and
autonomic activity resulting in bladder areflexia with a closed bladder neck. Over time
however, spinal cord injury may evolve into detrusor overactivity with sphincter
dysynergia.
• Cerebrovascular accident - thrombus or hemorrhage results in ischemia and infarction of
various areas of the brain. In the acute setting urinary retention from sphincter areflexia
may occur (the exact physiology is unclear). Over several weeks to months as the pt
recovers from the neurologic lesion a fixed deficit may become apparent.
• Cauda Equina, disc disease, spinal stenosis - back pain, lower extremity pain, cramping,
paresthesias related to exercise, and decreased rectal tone are common findings.
Urinary symptoms depend on the level of spinal cord compression.
• Radical pelvic surgery - Examples include abdominoperineal resection, proctocolectomy
or radical hysterectomy. Voiding dysfunction/urinary retention may occur due to pelvic
plexus injury. This usually improves over time, however in some cases may be
permanent. The pattern is usually one of impaired voluntary bladder contractility and
fixed striated sphincter tone.
• Diabetes - urinary retention in diabetes is usually the result of diabetic cystopathy.
Peripheral autonomic neuropathy in diabetes first affects sensory pathways causing
impaired bladder sensation. Gradual increase in time interval between voids results.
Over time, detrusor distention, overdistention and decompensation classically occur. As
a result, detrusor contractility is usually decreased in end stage diabetic bladder.
• Benign Prostatic Hyperplasia - the most common cause of urinary retention in males. As
men age, they undergo hyperplasia of benign prostatic tissue leading to gradual

Updated 6/2018 24
 narrowing of the bladder outlet and subsequent bladder hypertrophy. See prior chapter
on BPH.
• Post-Operative Retention - nociceptive impulses can inhibit initiation of reflex bladder
contraction through opioid-mediated mechanism or sympathetic mediated inhibition.
Alternatively, transient overdistention of the bladder can occur under anesthesia or due
to decreased sensation from the consumption of analgesic medications. Direct
neurologic injury due to disruption of the pelvic plexus can also occur as discussed
above.

Management

• Serial Post Void Residuals (PVRs) should always be measured when there is concern for
urinary retention. An increasing post void residual with inability of the patient to void
indicates acute retention while a stable but elevated post void residual usually indicates
chronic urinary retention.
• Other studies including upper tract imaging, cystoscopy, and urodynamics may be
indicated but are generally reserved for the outpatient setting and rarely have a role in
evaluation of acute urinary retention.
• General Recommendations for uncomplicated postoperative urinary retention o
Decompress the bladder (intermittent catheterization vs. indwelling Foley catheter)
o Minimize narcotic and anti-cholinergic medications
o If any symptoms of BPH based on history and physical exam start tamsulosin
0.4mg QHS (if no contraindications such as hypotension or sulfa allergy)
o Aggressive bowel regimen to ensure patient is having regular daily bowel
movements
o Prior to removing Foley catheter for a void trial ensure that the above criteria
have been met and that the pt is ambulating regularly (or at least at baseline
level of activity) is back to baseline mental status and that they do not have an
epidural in place
o If patient fails a void trial despite meeting the above criteria, further workup may
be indicated.

In the absence of neurologic injury and with proper decompression, voiding function will
generally return to preoperative levels. Return of bladder function may be facilitated with the
use of an alpha-blocker (eg. tamsulosin) as well as intermittent catheterization or placement of
an indwelling Foley catheter.

Treatment options

▪ Increasing intravesical pressure

o External Compression, Valsalva - controverstial but best used for patients
with atonic bladder and some striated or smooth sphincter denervation.

Updated 6/2018 25
 o Promotion or initiation of reflex contractions - manual stimulation of certain
areas within the sacral and lumbar dermatomes may provoke reflex bladder
contraction. The classic method is to apply manual rhythmic suprapubic
pressure.
o Pharmacotherapy
▪ Bethanechol chloride
o An acetylcholine-like drug with a relatively selective action on
the bladder. Though causes bladder muscle contraction in vitro,
results have been difficult to reproduce in vivo
▪ Alpha-adrenergic blockers
o Tamsulosin, Doxazosin, Terazosin, etc. - sympathetic signal inhibition
of pelvic parasympathetic ganglia promotes bladder storage. Thus
alpha-adrenergic blockers could facilitate transmission through these
ganglia to theoretically promote bladder contractility. More
commonly used for outlet obstruction (see below)
▪ Narcotic Antagonists
o Naloxone - theoretically prevents tonic inhibitory effect of
endogenous opiods on the bladder. Rarely used due to side effect
profile.
o Electrical Stimulation
o Sacral nerve root stimulation (Interstim). Mechanism of action has
not been completely elucidated.
▪ Reduction Cystoplasty
o Leads to myogenic decompression by
removing the chronically overstretched
muscle fibers of the dome of the
bladder. Risk benefit ratio is not well
established.
▪ Decreasing outlet resistance
o Pharmacotherapy
▪ Alpha-adrenergic blockers - promote relaxation of the smooth muscle of
the bladder neck and proximal urethera. May also affect striated
sphincter tone.
▪ Phenoxybenzamine - original drug used for voiding dysfunction. Now
rarely used due to high side effect profile
▪ Prazosin - first selective alpha-1 AR blocker. “First dose phenomenon“ of
faintness, dizziness and palpitaions thought to be due to acute postural
hypotension
▪ Terasosin / Doxazosin - highly selective post-synaptic alpha-1 AR blockers.
Well tolerated, good bioavailability, but must be dose titrated. Some

Updated 6/2018 26
 effect on blood pressure, thus often used in patients with concommittent
hypertension
▪ Alfuzosin / Tamsulosin / Silodosin - highly selective with preferential
action on prostatic rather than vascular smooth muscle. Less hypotensive
side effects. Do not need to be titrated.
o Surgical Management
▪ TURP/PVP
▪ TUR bladder Neck
▪ Transurethral incision of bladder neck
▪ Urethral Stricture dilation
o Other
▪ Conservative Management
▪ Indwelling Foley Catheter
▪ Suprapubic Tube
▪ Clean intermittent catheterization

Updated 6/2018 27
Acute Renal Colic Scott Gabrielsen, M.D., Ph.D. & Brian Eisner, M.D.

Definition: Acute onset, severe flank pain. Often intermittent in nature, may radiate toward groin.

Etiology: Usually secondary to acute obstruction of the urinary tract, most frequently from
nephrolithiasis. Acute urinary obstruction and ureteral dilation activates receptors in the urolthelium
(stretch and inflammation). Slow dilation of the system is often asymptomatic. Thus, the degree of
obstruction is not necessarily correlated with pain severity.

Evaluation: Goal is to rule out other causes of pain and determine if intervention is needed.
History: Location, onset, duration, nature of pain, associated symptoms

History of stones (#/frequency of episodes, composition, prior interventions)

Other GU problems/surgeries

Risk factors for complicated stones: DM, diversion, solitary kidney, pregnancy,
immunocompromised

Prior GU/abdominal procedures

History of malignancy

Exam: Vitals, general appearance, abdominal/GU exam

Labs: CBC, chemistry, UA (culture if positive)

Imaging:
RUS/KUB or stone protocol CT (start with KUB and RUS but consider CT if diagnosis of
stone is not made on initial imaging studies. Also can start with CT scan if
patient demonstrates hemodynamic instability or is toxic-appearing

Treatment Options (ureteral stones):

Medical Expulsive Therapy (MET)

Indications: ureteral stone <10 mm, pain/nausea well controlled on PO meds, patient tolerating
POs, no clinical evidence of sepsis, adequate renal function

Recommendations: alpha receptor antagonist, NSAIDs, prn narcotic pain

medication pain medication, stool softeners. Can use pyridium for dysuria
and anticholinergics for bothersome urinary frequency.

Follow up: Renal ultrasound/KUB within 4 weeks

Indications for Intervention: worsening colic, persistent obstruction, infection

Updated 6/2018 28
Surgical Intervention

1. Emergent ureteral stent or nephrostomy tube – hemodynamic instability with infection, anuric
renal failure due to obstruction with electrolyte abnormalities (e.g. solitary kidney, bilateral
obstruction)
2. Urgent ureteral stent or nephrostomy tube – fever without signs of hemodynamic instability,
obstruction with rising creatinine
3. Non-urgent – may do primary ureteroscopy or stent followed by ureteroscopy in these cases –
cannot take adequate PO intake due to nausea, stone > 10 mm, stone < 10 mm that fails to pass
with MET within 4-6 weeks
a. Definitive Treatment: shockwave lithotripsy (SWL), ureteroscopy with stone extraction or
laser lithotripsy, percutaneous nephrolithotomy

Patients with bacteriuria or other signs of infection should be treated with an appropriate course of
antibiotics (usually 5-7 days) prior to treatment of the stone.

Management of patients with fever and ureteral obstruction (risk for sepsis)

-Notify Senior resident/attending immediately

-Make NPO

-Two large bore, peripheral IVs, foley catheter, telemetry

-STAT urine culture, blood cultures, CBC, chemistry, PT/PTT, HCG

-Emergent/urgent OR for ureteral stent placement vs. IR for percutaneous nephrostomy tube.
Patient may need ICU bed following procedure.

-Consent and mark patient if going to OR

*If patient is very unstable, ureteral catheters can be placed at the bedside via flexible
cystoscopy (rare).

Updated 6/2018 29
Erectile Dysfunction Joseph W. McQuaid, MD

As defined by the 1993 NIH Consensus Development Panel on Impotence, erectile dysfunction
(ED) is defined as: “The inability of the male to achieve and maintain erection of the penis to
permit satisfactory sexual intercourse”. According to the Massachusetts Male Aging Study, 50%
of men aged 40-70 demonstrated some degree of ED. While this study has been criticized for
overestimating these numbers, this is a disease that is commonly encountered in any medical
practice and warrants a basic working knowledge, regardless of the medical specialty one
eventually chooses.

Physiology of Erection and Ejaculation

Sexual activity is initiated by the central nervous system at the level of the hypothalamus.
Descending parasympathetic and sympathetic pathways exit the brain, traveling through the
spinal cord to exit at the level of S2-4 (parasympathetic) and T10-L3 (sympathetic) respectively.
In order to initiate an erection, i.e. to generate tumescence of the two corpora cavernosa and
single corpus spongiosum, two major processes must occur. In the first, blood supply to the
penis actively increases roughly 20-40 fold compared with baseline. Penile blood volume
increases, the penis grows, and intercavernosal pressures rise. As a consequence of this, a
second more passive process occurs, as venous outflow from the corpora is limited by
compression of venules that typically allow for egress of blood in the flaccid state. The rapidly
expanding corpora cavernosa occlude these venules during erection, thereby limiting such
egress, trapping blood, and maintaining an erection. The aforementioned parasympathetic
nerves provide the inciting stimulant in this cascade, as they release nitric oxide from their
nerve endings. This in turn results in cavernosal arterial smooth muscle relaxation through a
cascade dependent upon increased cyclic GMP, decreased intracellular calcium, and decreased
muscular tone. Notably after a coordination of psychic and physical coordination, climax and
ejaculation are achieved. Sympathetic tone increases, resulting in a contraction of the bladder
neck (preventing retrograde ejaculation) and rhythmic muscular contraction of the
bulbocavernosus and bulbospongiosus muscles with resulting emission of semen.

Etiology of Erectile Dysfunction

As can be deduced from the physiology, there are multiple etiologies that must be considered
in a patient with ED. These include psychogenic, drug induced (pay attention to
antihypertensives and antidepressants including SSRIs), anatomic (including Peyronie’s
disease), hormonal (i.e. hypogonadism), neurogenic (secondary to any injury of peripheral
nerves not limited to prior prostatectomy, diabetes mellitus, multiple sclerosis, or spinal cord
injury), veno-occlusive dysfunction a.k.a. venous leak (an inability to trap blood within the
corpus cavernosa), and arteriogenic (secondary to inadequate arterial relaxation or pressures
as a result of atherosclerotic disease or trauma).

Updated 6/2018 30
Evaluation and Work-Up

Treatment must be goal-oriented, with emphasis on restoring “satisfactory” sexual activity.

Therefore, evaluation should be tailored accordingly; however, there are several basic studies
that should be considered in most patients. This includes a thorough medical history (including
surgical, psychological, social, trauma, and medication history) as well a thorough sexual history
(including onset and duration of ED, maximal rigidity, sustaining and penetrating capabilities,
morning erections, erections with masturbation, frequency of intercourse, libido, ejaculatory
dysfunction, orgasmic dysfunction, ability to achieve satisfactory sexual activity, penile
curvature, performance anxiety, depression, and stress). An IIEF questionnaire may be helpful
to documenting and quantifying some of these components. Special mention should be made
to cardiovascular risk. Not all patients presenting to a urology practice may not have adequate
primary care. At the very least a discussion and referral to a PCP is in order for a patient with
multiple risk factors for CAD. Ideally, a work-up can be initiated by the urologist including a
CBC, lipid panel, and fasting blood sugar. Similarly for patients previously diagnosed with CAD,
attention should be paid to whether the patient can tolerate the physical rigor (3-5 MET) of
sexual intercourse after his ED is addressed. There are several questionnaires available to
answer this question.

Routinely, patients undergo a basic endocrine evaluation during evaluation for ED including a
morning testosterone (to account for diurnal variations). If this is low, further tests may be
initiated including a prolactin level, LH, FSH, and repeat T. At this point, depending upon the
suspected etiology of a patient’s complaints, several specialized tests may be considered
including nocturnal penile tumescence and rigidity (NPTR, to distinguish between psychogenic
ED from organic causes), intravascular injection with papaverine or prostaglandin E1 (to rule
out veno-occlusive disease), cavernosometry and cavernosography (to detect a cavernosal leak
and resulting veno-occclusive disease), and penile arteriography (to detect arteriogenic causes).

Treatment for ED

Remember, prior to recommending therapy and sexual intercourse, patients must be cleared
from a cardiovascular perspective. Once this has been completed, several therapies may be
discussed. Note that this includes generalized therapy. Hormonal, severe arteriogenic,
venoocclusive, and anatomic etiologies require specialized treatments unto themselves that are
beyond the scope of this introduction.

Therapy Comments
General Recommendations Avoid smoking, maintain an ideal body weight,
stop alcohol abuse, discontinue offending
medications, optimize CAD risks.
Sex Therapy Organic therapies may be trialed in
combination with a sex therapist’s
recommendations.
Updated 6/2018 31
Phosphodiesterase Inhibitors (PDE5-I) First line therapy unless contraindicated (i.e.
taking nitrates or nitric oxide donors). Inhibit
the breakdown of cGMP and thereby maintain
low levels of intracellular calcium, relaxed
arterial tone, and improved arterial inflow.
Success rates are 70-80% however do require
stimulation i.e. these drugs sustain an erection
but do not stimulate.
Intracavernosal Injections Patients will inject Aloprostadil, a.k.a. PGE1,
into the cavernosa, resulting in increased
cAMP levels and decreased calcium in the
smooth muscle. This may be packaged with
other agents in a so-called “Tri-mix”.
Intraurethral Aloprostadil (MUSE) Similar in action to the intracavernosal
injections however this is less invasive.
Downside is decreased efficacy.
Vacuum Constriction Devices Instead of increasing arterial inflow, a pump is
placed over the penis and actually draws
blood retrograde into the corpora via the
venous sinuses. Thereafter, a clamp is placed
around the base of the penis to maintain
rigidity during intercourse. This is very safe
but has a high drop-out rate.
Penile Implants Definitive surgical management with high
efficacy but potential complications and need
for general anesthesia.

Updated 6/2018 32
Benign Prostatic Hyperplasia (BPH) Scott Gabrielsen MD/PhD

AUA guideline available at: https://www.auanet.org/education/guidelines/benign-

prostatichyperplasia.cfm

Definition

BPH is enlargement of the prostate due to hyperplasia of smooth muscle and epithelial cells
within the transition zone. Prostate growth is driven primarily by dihydrotestosterone (DHT)
and less by testosterone. Tone of the prostatic smooth muscle is regulated by α 1A-adrenergic
receptors. Lower urinary tract symptoms (LUTS) secondary to BPH can be related to storage
(frequency, urgency, incontinence and nocturia) or voiding (hesitancy, straining,
intermittency/weak stream, dysuria and incomplete emptying). Note, however, that prostate
size does not correlate well with symptoms. Bladder outlet obstruction secondary to BPH can
lead to gross hematuria, acute/chronic urinary retention, renal insufficiency, recurrent UTI and
bladder stones. Evaluation
Evaluation and treatment of BPH is generally reserved for patients with bothersome LUTS.
Diagnostic evaluation is primarily to rule out other less benign causes (e.g., prostate or bladder
cancer, neurologic disease, urethral stricture, etc.). Basic evaluation includes relevant medical
history including assessment of LUTS and severity and bother of the LUTS. Physical examination
should include a DRE. Laboratory evaluation should include a urinalysis and serum PSA. Further
evaluation is reserved for complicated LUTS (hematuria, elevated PSA, pain, infection, palpable
bladder and neurologic disease).

Treatment

Treatment of LUTS consists of conservative therapy, medical therapy and surgical therapy.

• Conservative therapy includes adjusting medications (avoiding, α-adrenergic agonists,

anticholinergics, diuretics), adjusting fluid intake, lifestyle changes (weight loss,
exercise), dietary changes (avoiding caffeine, alcohol).
• Medical therapy is the main first line treatment of LUTS secondary to BPH. Medications
include α-adrenergic receptor blockers, 5α reductase inhibitors, anticholinergics, PDE5
inhibitors, and combinations of these medications. Note, the AUA does not recommend
any complementary or alternative medicines.
o α-adrenergic receptor blockers decrease smooth muscle tone in the prostate. The
onset is rapid (24-48 hours). Side effects include orthostatic hypotension, dizziness
and retrograde ejaculation. Newer agents (e.g., tamsulosin, silodosin) are more
selective and have lower risks of orthostatic hypotension.

o 5α reductase inhibitors block conversion of testosterone to DHT and result in

decrease in prostate size. Full effect takes several months up to 1 year. Side effects
include gynecomastia, erectile dysfunction and decreased libido. Note that these

Updated 6/2018 33
 medications will decrease PSA by around 50%, so it is important to get a baseline
PSA prior to initiating therapy.

o Anticholinergics decrease LUTS (particularly irritative LUTS) secondary to

overactive bladder. Low risk of urinary retention if PVRs are low prior to initiating
therapy. Full effect takes up to 12 weeks. Side effects include constipation, dry
mouth, blurry vision and urinary retention.

Indications for surgical intervention

• Renal insufficiency secondary to BPH

• Recurrent UTIs, bladder stones or gross hematuria due to BPH
• LUTS refractory to other therapies

Options for surgical intervention

• Minimally invasive techniques (Transurethral needle ablation (TUNA), Transurethral

microwave thermotherapy (TUMT))
• Laser therapies (Photoselective vaporization of the prostate (PVP)*, holmium laser
resection (HoLRP)/enuclation (HoLEP)/ablation (HoLAP), homlium laser ablation
(HoLAP))
• Transurethral incision (TUIP)/vaporization (TUVP)/resection (TURP) of the prostate
• Open, laparoscopic or robotic prostatectomy*
Commonly Used α-Adrenergic Receptor Antagonists

Requires Adult Starting Maximum

Name Selectivity
Titration Dose Daily Dose
Terazosin Non-selective Yes 1 mg PO qHS 10 mg
Doxazosin IR Non-selective Yes 1 mg PO qD 8 mg
4 mg PO qD
Doxazosin ER Non-selective Maybe 8 mg
(before breakfast)
10 mg PO qD
Alfuzosin Non-selective No 10 mg
(after meal)
0.4 mg PO qD
Tamsulosin α-1A selective Maybe 0.8 mg
(after meal)
8 mg PO qD
Silodosin α-1A selective No 8 mg
(w/ meal)
Commonly Used 5α-Reductase Inhibitors

Updated 6/2018 34
 Type 2 5α-
Finasteride No 5 mg PO qD 5 mg
reductase
Type 1 & 2 5α-
Dutasteride No 0.5 mg PO qD 0.5 mg
reductase

Updated 6/2018 35
Evaluation of Scrotal Masses Russell Hayden, MD

Focused History

• Onset/Duration – When was the mass first noticed? Has any work-up been done
already by an outside provider? Check for prior scrotal ultrasounds in the medical
record.
• Infectious – Epididymo-orchitis is common. Ask about pain, redness, and warmth. Any
history of fevers or UTI symptoms (dysuria, frequency, urgency)? Risk factors include
high risk sexual practices, recent instrumentation, or prior history of epididymo-orchitis.
• Trauma – Be wary of any history of trauma. Many patients first notice their chronic
scrotal mass after a strike to the groin. Usually there is some component of denial.
• Neoplastic – Risk factors for testis cancer include cryptorchidism (patients sometimes
don’t realize they had this as an infant), family or personal history of testis cancer
(lymphoma as well), and infertility.
• Social history – Ask about marijuana use, as this may increase beta-HCG levels (which
you may ultimately send if testis cancer is suspected)
• Surgical history – Any scrotal surgeries in the past (vasectomy, orchidopexy,
hydrocelectomy)?

Focused Exam
• Non-scrotal findings –Check for gynecomastia, abdominal masses (retroperitoneal
masses), flank pain (ureteral obstruction), and lymph nodes (supraclavicular, groin).
Very large retroperitoneal masses may obstruct venous/lymphatic return from the lower
extremities.
• Scrotal findings (a warming pack may help loosen the scrotum to facilitate the exam) – Is
there overlying erythema or warmth? Any hydrocele (use transillumination)? Palpate
the cord and epididymis (check for induration, tenderness). Carefully palpate the testis
for any masses. Note that the epididymis will feel like a “worm” over the posterior
aspect, and can sometimes be confused for a mass by patients. Examine the scrotum
with the patient standing as well – varicoceles will become more apparent. Also have
the patient bear down in order to increase vascular pressure. RIGHT varicoceles should
raise concern for a retroperitoneal mass (compression of venous return) and mandates
retroperitoneal imaging. Examine for surgical scars keeping in mind that these can be
hard to see.
• Careful hernia exam: Sometimes people will mistake an inguinal hernia for a “testicular
mass”.

Updated 6/2018 36
Work-up
• Scrotal ultrasound – The testis is best studied with ultrasound. Be sure to order doppler
studies to assess for low blood flow (torsion), or hyperemia (infection).
• CT abdomen/pelvis – The lymphatic drainage of the testis follows its embryologic
descent. Thus, metastases and lymphadenopathy will first occur in the
retroperitoneum. However, if the patient has a history of scrotal surgery the lymphatic
drainage may be aberrant with a theoretical risk of spread to the external inguinal nodes
(and should be palpated). Remember, patients with a RIGHT varicocele should have
retroperitoneal imaging.
• Biomarkers – If testis cancer is of concern, send biomarkers to begin the work-up
(betaHCG, AFP, and LDH). Common factors that may increase biomarkers artificially:
marijuana use, other malignancies (liver, pancreatic, gastric, and lung), or liver
dysfunction

Updated 6/2018 37
Urinary Tract Infections Keyan Salari, MD,PhD

Urinary tract infection (UTI) refers to an infection of the urinary system. There are an estimate
150 million UTIs yearly worldwide, the majority of which manifest as uncomplicated bacterial
cystitis and occur mainly in females.

Definitions
Uncomplicated UTI – a non-complicated UTI in a female with a normal GU tract Complicated
UTI – a UTI in a patient with any of the following criteria:
• Immunocompromised (e.g., diabetes mellitus, HIV, on steroids or chemotherapy)
• Pregnant
• Male
• Pediatric
• Indwelling urinary catheter, stent, or drain
• Abnormal GU tract (BPH, stone, bladder diverticulum, neurogenic bladder,
vesicoureteral reflux)
• Renal insufficiency

Risk factors for UTIs

• Reduced urine flow: outflow obstruction, BPH, prostatic carcinoma, urethral stricture,
foreign body (calculus); neurogenic bladder; inadequate fluid uptake
• Promote colonization: sexual activity (increased inoculation), spermicide (increased
binding), estrogen depletion (increased binding), antimicrobial agents (decreased
indigenous flora)
• Facilitate Ascent: catheterization, urinary incontinence, residual urine with ischemia of
bladder wall

Common causative pathogens in adult UTIs: E. Coli (80% of outpatient UTIs), Klebsiella;
Enterobacter, Proteus, Pseudomonas, Staphylococcus saprophyticus (5 - 15%), Enterococcus,
Candida, Adenovirus type 11

Diagnosis of UTI
• Clinical symptoms. The most common form of UTI is cystitis (bladder infection)
characterized by irritative symptoms such as urinary urgency, frequency, dysuria, as well
as hematuria, foul-smelling urine, and suprapubic pain. These symptoms are also typical
for urethritis and prostatitis in addition to cystitis. Symptoms associated with "upper
urinary tract" infections, exemplified by pyelonephritis, may include those typical of
cystitis, as well as fever, rigors, flank or abdominal pain, and nausea and vomiting.
• Collection method. Analysis of the urine is critical in determining the likelihood of
infection. The method of urine collection is important to distinguish between
Updated 6/2018 38
 contamination and true infection. There are 3 commonly used methods of collection: a)
clean catch midstream voided urine, b) catheterized urine and c) suprapubically
aspirated urine. The most variable of these three is the midstream voided urine,
especially in females, where contamination of urine by vaginal or perineal organisms is
common during collection. Voided urines that are sterile or contain high colony counts
(>100,000) of a single bacteria correlate well with urine obtained by other methods.
• Urinalysis. A positive chemical (dipstick) leukocyte esterase is 64 - 90% specific and has a
similar level of sensitivity for UTI. The finding of nitrite positivity on urine dipstick,
indicating the conversion of nitrate to nitrite by gram negative bacteria (not gram
positive), is very specific but only about 50% sensitive for a urinary tract infection. The
finding of elevated white blood cells in the urine (pyuria) is the most sensitive indicator
of infection (>10 WBC/hpf on spun specimen is 95% sensitive but much less specific for a
UTI).
• Quantitative urine culture. In general, > 100K colonies/mL on urine culture is diagnostic
for UTI. However, the probability of a UTI does depends on the method of collection. In
general, lower colony counts obtained by sterile urethral catheterization or by
suprapubic aspiration can represent true infection, but clean catch, mid-stream urine
that harbors < 100K colonies/mL in a female requires further verification or repeat
sampling to confirm a UTI.
• Imaging. Patients with uncomplicated cystitis or uncomplicated pyelonephritis generally
do not benefit from imaging studies to look for anatomic abnormalities. In patients who
do not respond to treatment, or in patients with predisposing factors, imaging with
kidney and bladder ultrasound, or a non-contrast CT scan of the abdomen and pelvis
may be useful. Cystoscopic or ureteroscopic evaluation of the urinary tract is not
typically performed with uncomplicated UTI or pyelonephritis.
• Differential Diagnosis. Other pathogens, processes and conditions that can cause
symptoms that mimic UTI include:
Herpes genitalis (HSV), Urethritis, N. Gonorrhoeae, Chlamydia, Trichomonas, Vaginitis,
Prostatitis, Nephrolithiasis, Trauma, GU tuberculosis, GU neoplasm, Intra-abdominal
abscess, Sepsis from non-GU source
Management of UTI
• Treatment is based upon pathogen identification and the type and degree of clinical
illness, and presence or absence of other predisposing host factors. In general, the
treatment consists of hydration, relief of urinary tract obstruction, removal of foreign
body or catheter if feasible, and judicious use of antibiotics.
• The type and duration of antibiotic treatment is dependent on site of infection (if
known), host factors and severity of illness. Most antibiotics are highly concentrated in
the urine and therefore are very effective at clearing bacteria from the urinary tract.
When considering treatment, first determine whether the UTI is complicated or
uncomplicated in nature.

Updated 6/2018 39
Uncomplicated UTI (cystitis, some pyelonephritis):
• 3 day course of oral TMP/SMX is 95% effective; 7 days is no more effective.
• If TMP/SMX resistance is > 10 - 20% (U.S. West coast, Europe), use fluoroquinolones.
• Higher percentages of resistance to TMP/SMX also implies possible resistance to
ampicillin, cephalosporins, tetracycline. Other uncomplicated UTI:
• A full 7 - 10 day antibiotic course should be used in patients with: diabetes, symptom
duration before treatment of > 7 days, pregnancy, age >65 years, or past history of
pyelonephritis or UTI with resistant organisms Complicated UTI (acute pyelonephritis):
• Empiric parenteral treatment after culture with:
Ampicillin plus aminoglycoside or Ampicillin/ Vancomycin (for beta-lactam allergy) plus
aminoglycoside or third-generation cephalosporin (if no enterococcus)
• Adjust antibiotics according to culture results
• Blood cultures positive in 20 - 40% of patients
• Switch from parenteral to oral therapy at 48 hours after clinically well Treat for 14
days.
Acute pyelonephritis with intrarenal, perirenal or pararenal abscess
• Treatment for complicated UTI and add appropriate drainage.
Epididymitis
• TMP/SMX or fluoroquinolones for at least 3 weeks to obtain adequate tissue levels.
Acute bacterial prostatitis
• TMP/SMX or fluoroquinolones for at least 4 weeks to obtain adequate tissue levels
Chronic bacterial prostatitis
• TMP/SMX or fluoroquinolones for 6 - 12 weeks. Re-infection
• A test of cure should be undertaken by repeat culture in pregnancy, pyelonephritis, and
complicated or relapsing UTI.
• Re-infection is the relatively rapid recurrence of a UTI with the same or different
organism after cure has been documented.
• Each infectious episode should be treated separately.
• Consider 6 - 12 months of antibiotic prophylaxis (once a day oral intake of TMP/SMX or
nitrofurantoin at 1/3 to ½ of a daily treatment dose)
• For patients with recurrent cystitis related to coitus, consider self-administered
singledose antibiotics post-coital treatment. Relapsing infection
• Failure to clear or completely eradicate the pathogen despite a reasonable treatment
course
• Should trigger a urologic investigation that includes imaging to define possible
anatomical causes and prolonged therapy in the meantime.
Asymptomatic bacteriuria
• Generally, does not need treatment, except in pregnancy.
• Treatment is not indicated in the elderly (20 - 40% incidence) and patients on
catheterization (90% incidence).
Updated 6/2018 40
UROLOGIC ONCOLOGY

Renal Cell Carcinoma & Renal Cysts Francis J. McGovern, MD & Michael L. Blute, MD

Epidemiology, risk factors, and clinical presentation

• Approximately 64,000 people are diagnosed with kidney tumors on an annual basis:
39,140 cases in men and 24,780 cases in women, resulting in about 13,860 deaths
annually according to the American Cancer Society.
• Renal-Cell Carcinoma is the most common malignant kidney cancer in the adult
population, while Wilms Tumor is the most common kidney malignancy in the pediatric
age group.
• Renal-Cell Carcinoma represents 2% of adult cancers. Despite new treatments for
advanced (metastatic) kidney cancer, approximately 40% of patients may eventually die
from this disease.
• The average age at diagnosis is 64 years old. The lifetime risk of developing a kidney
cancer is 1.6% or 1 out of 63 people.
• Risk factors for developing kidney cancer include smoking, obesity as well as genetic
syndromes such as VHL or hereditary papillary RCC.
• Symptoms may include hematuria, flank pain or palpable mass; although the majority
present asymptomatic.
• Prior to the development of cross-sectional imaging, the majority of patients were
diagnosed by symptoms of flank pain or hematuria or mass on clinical examination.
Now the majority are diagnosed as incidental findings during imaging.

Diagnosis

• With the widespread use of radiologic imaging, CAT scan, MRI and ultrasound, the
detection of kidney lesions has risen significantly. I prefer the word lesion as this
includes both solid masses and cysts.
• The diagnostic challenge for the physicians is to determine whether a lesion is a
malignant vs. benign anatomic structure (i.e. simple cyst) vs. benign tumor (i.e. AML) vs.
an inflammatory lesion that gives the appearance of a malignant tumor. The role of
needle biopsy for renal masses is currently not well defined.
• The evaluation of a patient with a kidney mass usually includes a Renal Mass Protocol/
Abd CAT scan. If a solid mass is detected further, imaging of the chest with CXR or chest
CAT scan is performed to evaluate for metastatic disease to the lungs. Brain imaging is
limited to patients with new CNS symptoms/findings. New focal bone pain is evaluated

Updated 6/2018 41
 with MRI as bone scans are often not helpful as the metastasis are usually lytic and do
not show up well on a bone scan.

Consideration for renal mass biopsy

• Small renal masses ≤ 3cm due as 25% may be benign

• Renal mass in setting of other primary malignancy
• Suspected lymphoma
• Confirm malignancy prior to nephrectomy in patients with poor renal function
• Confirm malignancy in patients that are high risk surgical candidates
• Atypical/inflammatory masses which may be secondary to systemic process
Stages of kidney cancer

• Stage I: Malignant mass ≤7 cm, confined to the kidney

• Stage II: Masses >7 cm, confined to the kidney
• Stage III: Mass any size in kidney and o 1 or more regional lymph
nodes or o Invasion into perinephric fat or o Involvement of
venous system
• Stage IV: Mass any size in kidney and o Spread to other organs o
Invasion beyond perinephric fat

Management options for malignant renal masses:

Size Surveillance Biopsy prior Thermal Surgery: Surgery:
to Ablation Partial Total
Treatment Nephrectomy Nephrectomy
1 cm √ √ √ √
2 cm √ √ √ √
3 cm √* √ √ √
4 cm +/- √ √ +/ -
5 cm √ √
6 cm √ √
7 cm √ √
8 cm √
9 cm √
10 cm √
*If serious comorbidities

Basic facts regarding the size of renal masses

• Solid Masses ≤ 3 cm: o 75% malignant o 25% benign

Updated 6/2018 42
 • Solid Masses > 4 cm: o 90% malignant o 10% benign
• Risk of metastasis small for masses ≤ 3 cm
• Risk of metastasis increases with increasing size of renal mass
• Solid Masses that contain fat are most likely to be an AML (Angiomyolipoma)
Surgical management

Surgery is the primary treatment modality for RCC. The following are the types of surgery that
can be performed depending on size, location, and extension of the tumor.

• Radical Nephrectomy - Done for large tumors. Surgical techniques include open,
laparoscopic, hand assisted laparoscopic, robotic.
• Partial Nephrectomy: Done for smaller tumors. Depends on size and location of the
tumor. o Benefit - renal preservation
o Risks - delayed bleeding, urinary fistula/leaks
• Percutaneous thermal ablation: heat RFA or cold cryoablation. Done for small tumors <
4 cm. Peripheral location, away from ureter. Elderly patients, high risk surgical
candidates, serious comorbidities.

Facts regarding benign renal tumors

Benign renal tumors are also quite prevalent and often detected incidentally on imaging.
Approximately 25% of solid masses under 3 cm are benign. Benign renal masses are often
followed with imaging by yearly renal ultra sound

• Angiomyolipomas (AML) – these lesions are very common. These tumors are composed
of vascular, muscle and folly components. 80% are sporadic. Average age of diagnosis is
early 40’s and female: male ratio of 4:1. 20% occur with the genetic syndromes most
commonly tuberous sclerosis. When associated with tuberous sclerosis the tumors are
diagnosed at a young age often large and multiple. AML’s may present as an imaging
finding of fat within a renal mass. Some present clinically secondary to renal
hemorrhage secondary to their predisposition to bleeding.
o Management of asymptomatic AML’s < 4cm is now usually active surveillance. I
obtain annual renal U/S after initial diagnosis. AML’s greater than 4 cm or AML’s
which have had a bleed are usually managed with angioembolization.
o Percutaneous Ablation or surgeries are being utilized much less in the
management of AML as both imaging and angioembolization has improved.
• Renal adenoma - small benign growths
• Oncocytoma - may grow to large size, some have a central scar others are
indistinguishable from RCC.
• Fibroma - originate from fibrous capsule more common in females.
• Lipoma - originate from fat within the kidney
• Metanephric Adenoma: occasionally seen in association with polycythemia
Updated 6/2018 43
Renal Cysts

Renal Cysts are the most common kidney lesions.

• Fluid density on CAT scan

• Occur in approximately 50% of adults over age 50
• Usually asymptomatic
• Most do not require treatment as the majority of renal cysts are benign
• Very large cysts may be symptomatic
• Dr. Bosniak developed a classification system based on anatomic appearance of the cyst
that has been used clinically to determine risk of malignancy.
Type Characteristics Risk of malignancy Management

I Simple thin wall no < 2% Observation

enhancement

II Above plus may have a few 14% Observation

thin wall septa which do
not enhance fine
calcifications are okay

IIF Above plus multiple 14-24% Active surveillance w/

nonenhancing septa some repeat imaging
septa are thickened but do
not enhance calcifications
ok
III Thick walls/ septa which 50% Surgical or Thermal
enhance Ablation

IV Above plus enhancing 90% Surgical or Thermal

masses Ablation

Updated 6/2018 44
Upper tract urothelial carcinoma Aria F. Olumi, MD

Introduction

Upper tract urothelial carcinoma (UTUC) is a rare disease with approximately 3000 new cases
per year in the United States. Much like urothelial cancer of the bladder (UCB), UTUC is
heterogeneous with significant variability in disease characteristics and patient outcomes.
Approximately 90% of tumors originating from the upper urinary tract are urothelial in origin
while the majority of the remaining 10% are squamous cell carcinomas.

Epidemiology/risk factors

The incidence of UTUC is rising, and there is a concurrent shift towards earlier stage disease.
UTUC is more common in men, whites and at older ages with a mean age at diagnosis in the
mid-70s. Approximately 50% of patients with UTUC will develop UCB in their lifetime, whether
these bladder tumors represent ‘drop metastases’ from the upper urinary tract or develop de
novo from a pan-urothelial field defect is unclear. In contrast, patients with an initial diagnosis
of UCB have about a 5-20% lifetime chance of developing UTUC. Both UCB and UTUC patients
require periodic surveillance of both their upper urinary tract (kidneys and ureters) and lower
urinary tract (bladder and urethra). Smoking is the most significant modifiable risk factor.

Clinical presentation/evaluation

Most patients present with hematuria and/or flank pain. Rarely, a flank mass is palpable on
physical exam. Frequently, a CT urogram (with delayed films to evaluate the renal pelvis and
ureters) is performed to identify the tumor. Ureteroscopic biopsy is required to obtain a tissue
diagnosis. The location of the tumor (distal ureter is the most common site), tumor grade,
tumor stage, focality and the presence of concomitant bladder tumors all have a dramatic
impact on treatment strategies. Local primary tumor stage is difficult to accurately assess both
radiographically and endoscopically. If the tumor is high grade, large or locally advanced, a full
metastatic workup including chest and abdomen/pelvis imaging as well as possibly a bone scan
are required.

Staging
Primary Tumor (T)
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Ta Papillary non-invasive carcinoma
T1 Tumor invades subepithelial connective tissue
T2 Tumor invades the muscularis

Updated 6/2018 45
T3 Tumor invades the periureteric fat, peripelvic fat or renal
parenchyma
T4 Tumor invades adjacent organs or into the perinephric fat

Regional Lymph Nodes (N)

Nx Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node, <2cm in greatest
diameter
N2 Metastasis in a single lymph node between 2-5cm in
diameter, or multiple lymph nodes < 5cm in diameter
N3 Metastasis in a lymph node > 5cm in diameter

Distant Metastasis (M)

Mx Distant metastasis cannot be assessed

M0 No distant metastasis
M1 Distant metastasis

Treatment of localized disease

Surgical excision is the standard of care in localized UTUC. Nephroureterectomy (excision of the
entire kidney and ipsilateral ureter with a cuff of bladder mucosa) is the gold standard for most
UTUC patients. Distal ureterectomy with ureteral reimplantation can be considered for some
distal ureteral tumors, especially locally confined, low grade carcinomas. Endoscopic
ablation/resection, either ureteroscopic for ureteral tumors or percutaneous
ureteropyeloscopic resection for large renal pelvis or proximal ureteral tumors, can be
considered in either small, low grade tumors or when nephroureterectomy would cause
significant renal dysfunction such as patients with a solitary kidney, bilateral UTUC or severe
pre-existing chronic renal disease.

The integration of systemic chemotherapy, and the role of lymphadenectomy are two ongoing
clinical dilemmas in the treatment of locally advanced UTUC. Many patients are ineligible for
cis-platinum based chemotherapy after nephroureterectomy which favors neoadjuvant
chemotherapy administration7. However, the lack of clinical trials supporting the use of
neoadjuvant chemotherapy for UTUC limits its use, as does the ability to properly ‘stage’ UTUC
prior to surgery. Lymphadenectomy plays an important role in assessing the extent of disease

Updated 6/2018 46
but there is limited data to suggest that this offers a survival advantage8. Further the lymphatic
drainage of UTUC has not been rigorously defined.

Treatment of metastatic disease

Metastastic disease is treated with systemic chemotherapy. First line therapies include GC
(gemcitabine and cis-platinum) or MVAC (methotrexate, vinblastine, adriamycin and
cisplatinum)

Prognosis

Metastastic disease is almost uniformly fatal. In the non-metastatic setting, the extent of local
disease has dramatic impact on survival. The 5 year cancer specific survival after
nephroureterectomy for locally confined disease is >90% for T0-T1, ~75% for T2, ~50% for T3
and ~10% for T4. There does not appear to be a significant difference in outcomes based on
the location of the primary tumor (renal pelvis vs ureter).

Updated 6/2018 47
Bladder cancer Aria F. Olumi, MD

Epidemiology/risk factors/clinical presentation

The epithelial lining comprising the renal pelvis, ureter, bladder and proximal urethra is from
transitional cell epithelium. Transitional cell carcinomas (TCC) comprises more than 90% of all
urothelial cancers in the United States. Adenocarcinoma (2%), squamous cell carcinoma
(510%), undifferentiated carcinomas (2%) and mixed carcinomas (4-6%) are other types of
urothelial malignancies. TCC commonly appear as papillary and exophytic lesions.

Cancer of the bladder is the fourth most common cancer in men and the tenth in women. More
than 56,000 people (41,500 males and 15,000 females) develop bladder cancer each year in the
United States, and 12,600 individuals (8,600 males and 4,000 females) are expected to die from
the disease.

The surface epithelium (urothelium)

that lines the mucosal surfaces of the
entire urinary tract is exposed to
potential carcinogens that may be
excreted in the urine, or activated in
the urine by hydrolyzing enzymes.
Environmental exposures are thought
to account for most cases of urothelial
cancer. For example, a link between
environmental factors and TCC of the
urothelium was first suggested by the
increased incidence of TCC in Figure 3. Staging of bladder cancer. Stages Tis, Ta and T1
industrialized societies and urban are considered superficial bladder cancer, while higher
dwellers. Secondly, increased stages are considered muscle invasive .
incidence of renal pelvis and bladder
carcinoma has been reported in aniline dye workers. Exposure to chemicals used in the
aluminum, dye, paint, petroleum, rubber, and textile industries have been estimated to
account for up to 20 percent of all bladder cancer cases. Hairdressers and barbers have an
excess risk of bladder cancer that is thought to be related to long-term exposure to
permanent hair dyes. In most cases, the suspect carcinogens are arylamines or their
derivatives that take several years to accumulate, thus accounting for the long latency period
before the development of bladder cancer.

Clinical manifestation of urothelial carcinoma includes gross or microscopic hematuria, which is

the most common symptom at the time of presentation, occurring in 70 to 95 percent of

Updated 6/2018 48
patients. For renal pelvis and ureteral malignancies flank pain occurs in 8 to 40 percent, may be
precipitated by obstruction of the ureter or ureteropelvic junction due to the tumor mass.
Bladder irritation, or constitutional symptoms, occurs in less than 10 percent urothelial
malignancies.

In patients with renal pelvis or ureteral tumor diagnosis is commonly made by radiologic
modalities that may include CT scan, IVP, or retrograde pyelography. Ureteroscopy has been
used for confirming any upper urinary tract malignancies when radiologic modalities are not
confirmatory. Cystoscopy is the main procedure used for diagnosing bladder carcinoma (Fig. 2).

Staging of urothelial malignancy is dependent on the depth of invasion of the tumor through
the submucosal musculature or adjacent organs. Figure 3 demonstrates the staging system
most commonly used for bladder carcinoma. More than 70% of all newly diagnosed bladder
cancers are superficial, approximately 50-70% are Ta, 20-30% are T1, and 10% are carcinoma in
situ (CIS).

The standard treatment for renal pelvis and upper ureteral urothelial carcinomas includes
complete nephroureterectomy with excision of the distal ureteral cuff from the bladder. Distal
ureteral tumors can be treated with segmental resection followed by reimplantation of the
remainder of the ureter into the bladder. The initial treatment options for bladder carcinoma
are dictated by the tumor stage, grade, size and number of tumors detected. In general, low
grade, superficial tumors are treated by transurethral resection of bladder tumor (TURBT) – an
endoscopic minimally invasive procedure. In some cases, intravesical agents may be used to
treat patients with bladder cancer. A commonly used intravesical agent is Bacille Calmette
Guérin (BCG), an attenuated strain of Mycobacterium bovis, rendered completely avirulent by
long-term cultivation on bile-glycero-potato medium, used in BCG vaccine for immunization
against tuberculosis. Often used for management of recurrent superficial bladder cancer or
multifocal bladder cancer, BCG is introduced intravesically approximately 4 weeks after TURBT
allowing for the urothelial lining to heal and minimizing the risk of BCG dissemination, which
can lead to severe sepsis. BCG has been shown to induce an MHC-mediated immuno-response
against bladder cancer thus reducing the recurrence rate of bladder cancer.

Updated 6/2018 49
Muscle invasive tumors (stage T2 or higher) are usually treated with radical cystectomy,
pelvic node dissection and urinary diversion. In
certain circumstances, systemic chemotherapy may
be used in the neoadjuvant setting (prior to surgery)
or in the adjuvant setting (after surgery).

For urinary diversion, a portion of small and/or large

bowel is often used for creation of a urinary
reservoir. The most commonly utilized form of
urinary diversion is an ileal loop urinary diversion
(Fig. 4) – a 15-20 cm segment of the distal ileum is
separated from the gastrointestinal tract while
keeping the mesenteric blood supply intact.
Continuity ot GI tract is re-established. The end of
Figure 4. Ileal loop urinary diversion
the ileal loop is closed and the two ureters are
anastomosed into the proximal portion of the ileal
loop. The distal end of the ileal loop is externalized through the abdominal wall and a urinary
stoma bag is used to collect the urine.

In contrast to the ileal loop urinary diversion that requires constant drainage of urine into a
stoma bag, continent cutaneous urinary reservoirs, which partly utilize the ileo-cecal valve for
their continent mechanism, are catheterized four to six times per day to drain the urine and do
not require appliance of an abdominal urinary stoma.

Another form of urinary diversion is an orthotopic neobladder (Fig. 5). For this type of urinary
diversion, a 40-45 cm segment of bowel is
detubularized and restructured in an elliptical
form which resembles the shape of a native
bladder. The two ureters are anastomosed into
40-45cm segment of distal the proximal portion of the pouch, while the
ileum
most dependent portion of the pouch is
Ureter anastomosed
into
anastomosed to the urethra in order to create a
proximal portion of neobladder. The biggest advantage of a
neobladder
neobladder is the absence of an abdominal
Creation of an ellipsoid urinary stoma for an ileal loop urinary reservoir
neobladder from
detubularized small or the need for catheterization and drainage for a
bowel continent cutaneous reservoir.

Anastomosis
to urethra
Early complications after urinary diversion
Figure 5. Orthotopic neobladder. include excessive bleeding, intestinal obstruction,

Updated 6/2018 50
 urinary extravasation and infection. Late complications include metabolic disorders, stomal
stenosis, pyelonephritis and formation of calculi. Metabolic abnormalities associated with
colonic urinary diversions are dependent on the length and segment of bowel used in the
urinary diversion. In general when ileum and/or large bowel are used for urinary diversion,
hyperchloremic metabolic acidosis may manifest. A potential complication of chronic long-
term metabolic acidosis may be decreased bone calcium content and osteomalacia.

Updated 6/2018 51
Prostate Cancer Seth Bechis, MD

D’Amico Prostate Cancer Risk Categories

• Risk PSA Gleason Score TNM Stage
• Low <=10 <=6 <=T2a
• Int. 10-20 7 T2b
• High >20 >=8 >=T2c

Prostate Cancer: Treatment Options for Localized Disease (T1-2, N0, M0)
Include radical prostatectomy (RP), external beam radiation (XRT), brachytherapy (+/-
XRT), active surveillance, cryotherapy, high frequency ultrasound

Active Surveillance
• Patient-driven form of delayed treatment with active monitoring for disease progression
(As opposed to watchful waiting, which does not involve monitoring and is palliative only) --
unclear who is optimal candidate; consider patients with <10 yr life expectancy, organ
confined disease, low grade disease, low volume cancer (<3 + biopsy cores, <50% of each
core) Pros: decrease overtreatment of insignificant prostate cancer and avoid side effects of
treatment
Cons: may miss window to cure, requires multiple prostate biopsies, no guarantee that tumor is
indolent
• Surveillance protocol: DRE/PSA every 6 months, prostate biopsy every year, possible
prostate MRI
• When to progress to treatment: Gleason >=4, >=3 positive biopsy cores, >50% of a
biopsy core is positive

Radical Prostatectomy
Gold standard for localized prostate cancer for men <75yrs
Common surgical options: open, laparoscopic, robotic assisted
• Pros: potential cure, more accurate staging (direct specimen for pathology)
• Cons: potential side effects (ie, urinary incontinence that usually resolves after 3-6
months, erectile dysfunction early postop if nerves affected), major surgery
• Postop: expect PSA to drop to <0.2 ng/Ml
o If PSA>0.2ng/mL will need to consider radiation therapy and/or androgen
deprivation therapy (ADT)
o If 33% will have biochemical recurrence
o 50% of post-radical prostatectomy patients with biochemical recurrence will die
from prostate cancer
o median time from post-prostatectomy PSA failure to metastases: 8 years o
median time from metastases to death: 5 years

Updated 6/2018 52
Pelvic Lymph Node Dissection
Indicated for patients in the intermediate to high risk categories

External Beam Radiation Therapy (EBRT)

• Treated 5 days per week for approx. 8 weeks
• Intensity Modulated Radiotherapy (IMRT): advanced form of 3D therapy. Uses a
computer-driven machine that shapes the beams at different angles.
• Proton Beam: focuses beams of protons instead of XRays. XRays release energy both
before and after they hit their target, whereas protons cause little damage to tissues
they pass through and release their energy only after traveling a certain distance. Proton
beam can, in theory, delivery more radiation to the prostate while doing less damage to
nearby normal tissues. Studies have not shown that proton beam is any better in the
long run than any other types of radiation.
• Consider adding ADT for intermediate risk (6 months of ADT) or high risk (2-3 years)
Pros: no surgery needed. Daily radiation treatment is fast.
• Cons: daily treatments for 8 weeks.
• Side Effects: Bowel problems (radiation proctitis) with diarrhea, blood in stool, rectal
leakage (usually resolve with time). Bladder problems (radiation cystitis) with frequency,
urgency, dysuria, and hematuria (1 in 3 men has longterm urgency or frequency).
Urinary incontinence (less common that after prostatectomy). Erection problems and
impotence slowly worsens over time and is equivalent to surgery after 3-4 years.
Fatigue. Urethral stricture. Lymphedema.
• Post-radiation Recurrence: defined as PSA rise to [PSA nadir +2] (Phoenix criteria)

Brachytherapy
• Permanent seeds (each the size of a grain of rice) implanted in the prostate. Used in
men with early stage prostate cancer that is slow growing. Iodine-125 (half-life 60 days)
or palladium-103 (half-life 17 days) are used
• Avoid in men with prostate size >60g, history of previous TURP or significant voiding
symptoms (they have a higher risk of post-treatment urinary side effects)
• Side effects: lower urinary tract voiding symptoms is common for 4-5 half-lives. Urinary
retention. Bowel problems. Erection problems (comparable to EBRT).

Cryoablation
• Active, rapid freeze cycle via Argon and active thaw cycle via Helium. Requires 2 cycles.
• Freezes the entire prostate to -40 degrees C
• Useful for low risk, localized prostate cancer
• Side effects: very high erectile dysfunction rate

Updated 6/2018 53
High Intensity Focused Ultrasound (HIFU)
• Not yet FDA approved for prostate cancer

Which is Best?
• For men <50yrs old, RP is the treatment of choice (higher 15 yr cancer specific and
overall survival)
• For low risk PCA in men >=50, RP, XRT brachytherapy and cryotherapy appear to have
similar cure rates
• For high risk cancer in men >=50, no significant differences in cure rates between RP
alone or XRT alone

Prostate Cancer: Treatment Options for Locally Advanced Disease (T3-4, N0-1, M0) Include
radical prostatectomy (RP), external beam radiation (XRT), androgen deprivation therapy
(ADT)

Radical Prostatectomy
• Select patients with clinically, local, advanced prostate cancer (T3) but will likely need
adjuvant treatment
• post-prostatectomy findings on pathology of local spread: positive surgical margin,
seminal vesical involvement (SVI), extracapsular extension (ECE), lymph node
involvement
• adjuvant radiation treatment (immediately after surgery when PSA is <0.2) is superior to
salvage (wait for PSA to rise to >0.2) if specimen had positive surgical margin, SVI or ECE

Radiotherapy (EBRT)
• Clinically used for T3 disease, although now offering radical prostatectomy as well

Androgen Deprivation Therapy (ADT)

• Not a curative treatment but may offer long term remission
• Early ADT may be beneficial in high risk patients with pT3 disease
• Intermittent ADT may be an option in some patients and improve quality of life
• important to prevent osteoporosis when treating with ADT
--baseline DEXA scan, then every 1-2 years
--vitamin D, calcium supplementation
--behavioral changes: smoking cessation, weight bearing exercise ADT
methods:
o Gonadotropin-releasing hormone (GnRH) agonist (Leuprolide, Goserelin) - Initial
transient androgen elevation, then suppression in 21-28 days. Transient
testosterone flare due to initial stimulation of LH. Suppress flare with

Updated 6/2018 54
 nonsteroidal antiandrogen such as bicalutamide or flutamide). Side effects:
decreased libido, erectile dysfunction, fatigue, weight gain, hot flashes, loss of
muscle mass, gynecomastia, testicular atrophy, diabetes, cardiovascular disease,
metabolic syndrome, anemia, bone demineralization
o GnRH antagonist (Degarelix, Abarelix) - No early flare phenomenon o Non-
steroidal antiandrogen (bicalutamide, flutamide) - competitively inhibits
androgens from binding androgen receptors. Not adequate on their own for
treatment of prostate cancer. Good to suppress the initial 28-day flare
phenomenon when starting GnRH agonists. Side effects: hepatotoxicity,
gynecomastia, breast pain, glucose intolerance, diarrhea, night vision blindness
o Bilateral orchiectomy - castrate levels within 24 hours

Prostate Cancer: Treatment Options for Castrate-Resistant Prostate Cancer (CPRC)

Definition: prostate cancer progression despite adequate testosterone suppression --continue
ADT indefinitely at this point

Prechemotherapy
Sipuleucel-T
• Immunotherapy; autologous CD54+ dendritic cells are activated with recombinant
prostate acid phosphatase to stimulate T cell production of cytokines
• Three doses given at 2 week intervals
• Indication: asymptomatic or minimally symptomatic CRPC
• Side Effects: flu-like symptoms due to cytokine release; acute infusion reactions
• IMPACT Trial: Overall survival 25.8 months (Sipuleucel-T group) vs 21.7 months (control
group)

Abiraterone acetate
• CYP 17 inhibitor-->prevents biosynthesis of testosterone (in adrenals, testes and
prostate cancer cells)-->decreases overall body androgen levels
• leads to excess aldosterone, which can cause hypokalemia and fluid retention
• also inhibits cortisone synthesis, so need to give prednisone PO daily
• give with prednisone PO daily to supplement
• Indication: pre- or post-chemotherapy for metastatic CPRC
• Side Effects: HTN, hypokalemia and fluid retention (due to aldosterone excess), adrenal
insufficiency, fatigue, edema, hot flashes, GI upset, hepatotoxicity (monitor ALT, AST,
bilirubin every 2-4 weeks)

Chemotherapy Docetaxel
• Taxane; stabilizes microtubules and allows apoptosis that was lost in prostate cancer
Drug of choice for metastatic CPRC
• TAX327 study: superior to mitoxantrone (18.9 months vs 16.4 months overall survival)
Updated 6/2018 55
 • Side Effects: myelosuppression, fatigue, neurotoxicity, hyperlacrimation, edema, liver
dysfunction

Cabazitaxel
• Taxane
• 2nd line chemotherapy for metastatic CPRC if progresses or fails docetaxel
• TROPIC trial: 15.1 months vs 12.7 months mitoxantrone overall survival
• Side Effects: myelosuppression, diarrhea, fatigue, peripheral neuropathy

Mitoxantrone
• chemotherapy to treat symptoms from metastasis; palliative therapy only

Post-chemotherapy
Abiraterone acetate
• Overall survival benefit post chemotherapy vs placebo

Enzalutamide
• Androgen receptor modulator: inhiits androgen binding to androgen receptors, inhibits
androgen nuclear receptor translocation, and inhibits DNA binding and activation of
androgen receptors
• AFFIRM trial: improved overall survival vs placebo (18.4 vs 13.6 mos)
• Side effects: fatigue, hot flashes, diarrhea, seizures (1%)

Emergency: Epidural Cord Compression

Symptoms: lower extremity weakness, sensory loss, loss of control of urination or bowel
movements, loss of anal sphincter tone on exam
Treatment:
o immediate IV dexamethasone (10mg loading dose, then 4-10mg q6hrs)
o MRI to evaluate for cord compression
o radiation therapy: definitive treatment
o surgical decompression before radiation may improve outcomes
o Ketoconazole high dose inhibits 17-alpha-hydroxylase and CYP17,
stopping androgen production in the testes and adrenal glands. Fast acting—
works as quickly as 4 hours. Bilateral orchiectomy is another option to
castrate.

Updated 6/2018 56
PROCEDURES

Urinary Catheters/Bladder irrigation Anton Wintner, MD

Types of urinary catheters

• Foley catheter o Comes in a variety of materials (latex) and diameters (most

common sizes are 10 F to 28 F. 1 F is equivalent to 0.33 mm = .013" = 1/77" and
balloon sizes are measured in cc’s.
• Coudé catheter o Coudé is French for “elbowed”
o Has a stiffer tip and a 45° bend at the tip to allow easier passage through an
enlarged prostate
• Council tip catheter o Has a hole at the tip that allows it to be passed over a wire
• 3-way catheter o Has a third channel, which is used to infuse sterile saline or
another irrigating solution
o Used primarily after surgery on the bladder or prostate to wash away urokinase
and dilute any ongoing bleeding to prevent obstruction of the catheter with clots
• Hematuria catheter o A combination catheter used in select cases of more
significant bleeding from the urinary tract
o Has 3 channels, a stiffer shaft, an elbowed tip and larger openings at the tip
o Easier to manually irrigate larger blood clots through which may obstruct other
catheters
• Whistle tip catheter o A single lumen catheter which is optimal for removing blood
clots from the bladder with hand irrigation
o Should always be used prior to placement of a 3-way catheter to ensure the
bladder is free of clots

How to Place a Urinary Catheter in a Male patient

1. Position the patient supine, in bed, and uncover the genitalia.

2. Open the catheter tray and place it on the bed between the patient’s legs; use the
sterile package as an extended sterile field.

3. Open the iodine prep solution and pour it onto the sterile cotton balls. Open two 10-mL
syringe and sterile 2% lidocaine gel (Urojets) and place them on the sterile field.

Updated 6/2018 57
 4. Use the sterile drapes that are provided with the catheter tray to create a sterile field
around the penis.

5. Put on the sterile gloves and use the nondominant hand to hold the penis and retract
the foreskin (if present). This hand is the nonsterile hand and holds the penis throughout
the procedure.

6. Use the sterile hand and sterile forceps to prep the urethra and glans in circular motions
with at least 3 different cotton balls.

7. Instill 20 mL of lidocaine gel into the urethra. Place a finger on the meatus to help
prevent spillage of the anesthetic lubricant. Hold the catheter with the sterile hand.

8. While holding the penis perpendicular (90°) to floor stretching it upward to straighten
the penile urethra, slowly and gently introduce the catheter into the urethra. Continue
to advance the catheter until the proximal Y-shaped ports are at the meatus

9. Wait for urine to drain from the larger port to ensure that the distal end of the catheter
is in the urethra. The lubricant jelly–filled distal catheter openings may delay urine
return. If no spontaneous return of urine occurs, try attaching a 60-mL syringe to
aspirate urine. If urine return is still not visible, withdraw the catheter and reattempt the
procedure.

10. After visualization of urine return (and while the proximal ports are at the level of the
meatus), inflate the distal balloon by injecting 10 mL of sterile water (for a 10ml balloon,
or 30mL for a 30mL balloon) through the cuff inflation port.

11. Gently withdraw the catheter from the urethra until resistance is met. Secure the
catheter to the patient's thigh with a wide tape. Creating a gutter to elevate the
catheter from the thigh may increase the patient's comfort. If the patient is
uncircumcised, make sure to reduce the foreskin, as failure to do so can cause
paraphimosis.

• Insertion of a Coudé catheter

o The Coudé catheter, which is stiffer and has a curved tip, was designed to
overcome urethral obstruction that a straight more flexible catheter cannot
negotiate (eg, in patients with benign prostatic hypertrophy). To place a Coudé
catheter, follow the procedure described above. The tip of the catheter and the
balloon port should face the patient’s cephlad when perpendicular to the floor
(ceiling when parallel to the floor).

• Perineal pressure assistance

Updated 6/2018 58
 o The distal tip of the catheter might become caught in the posterior fold between
the urethra and the urogenital diaphragm. An assistant can apply upward
pressure to the perineum while the catheter is advanced to direct the catheter
tip upward through the urogenital diaphragm.

• Removal of urinary catheter

o Use a syringe to empty the balloon, and then apply gentle traction. Pain, severe
discomfort, resistance to withdrawal of the catheter, or failure to aspirate
normal saline through the inflation valve should alert the practitioner to the
possibility of a nondeflating urethral catheter.

o The most common cause of a nondeflating urethral catheter is obstruction of the

inflation channel, caused by a failed inflation valve or crystallization of the
inflation fluid (this is why water should be used instead of saline).

o The first step in managing the nondeflating Foley balloon is to advance the
catheter to ensure that it is actually in the bladder.

o If this does not work, cut the balloon port proximal to the inflation valve. This
removes the valve and should allow the water to spontaneously drain.

o If this does not work, run a lubricated fine-gauge guidewire through the inflation
channel. The guidewire or stylet should allow fluid to drain along the wire itself.

o If this does not work, a 22-gauge central venous catheter can be passed over the
guidewire. When the catheter tip is in the balloon, the wire can be removed, and
the balloon should drain.

o If the above techniques are unsuccessful, 10 mL of mineral oil may be injected

through the inflation port and will dissolve the balloon within 15 minutes. If this
does not occur, an additional 10 mL can be instilled.

o If none of the above techniques are successful, a urologist or interventional

radiologist should be consulted to rupture the Foley balloon with a sharp
instrument.

Common scenarios leading to difficult catheter placement

PATIENT COMMON PROBLEM SOLUTION

Updated 6/2018 59
Female with challenging Difficulty locating the Place two fingers in the
anatomy urethral meatus vagina (finger pads pointing
ventrally) and run catheter
along fingers until it
engages the urethral
meatus
h/o BPH with resistance Difficult for a catheter to Try a larger gauge (18 or
met at the level of the navigate the prostatic 20fr) Coudé catheter
prostate urethra due to prostatic
obstruction

h/o Prostate surgery with Catheter becomes lodged in Try a smaller gauge Coudé
resistance met at the level a TURP defect, high bladder catheter (12 or 14fr). If
of the prostate neck, or bladder neck resistance continues to be
contracture met, cystoscopy may be
required
Phimosis/ obesity Difficulty visualizing the Place a finger between the
meatus foreskin and the glans and
blindly slide a catheter into
the meatus.
Meatal stenosis Opening of the meatus is Serially dilate with
too small to pass a catheter progressively larger
catheters. May start with a
pediatric feeding tube. If
the pt is in acute urinary
retention a flexitip catheter
can usually be passed into
the bladder for temporary
drainage.
Hypospadias True meatus is located Locate the true meatus and
ventral to its expected place a catheter as usual
location
Blood at the meatus/ False pass Try a Coudé catheter. A
catheter coils in the significant false pass
perineum however may require
cystoscopy. If the prostate
is actively oozing from the
false pass, try a 30mL
balloon to provide some
tamponade.
Updated 6/2018 60
Other useful tips

• Always use a minimum of 2 urojets to stent the urethra open

• 18Fr coude is default based on stiffness; work your way down in size if this doesn’t work
(12Fr is smallest). Rotate catheter and attempt advancement in case stricture is offset.
Try 14Fr->12Fr silicone catheters next; stiff so won’t coil and small if stricture
• Then try 10Fr->8Fr pedi feeding tubes (located in Jackson supply room) – in cases of
emergencies can use these to temporarily drain the bladder while getting ready for
cystoscopy.
• Cystoscopy cart if the above doesn’t work
Bladder irrigation
• From Jackson Supply or ED Urgent Supply Room:
o Whistle tip catheters (24Fr is good default size but grab 22 and 20 as well; 18 is
kind of small to irrigate but may needed if stricture as well). **these are latex;
see below if latex allergic
o 3-way catheters in same sizes as whistle tip; if likely prostate bleed – grab ones
with 30cc balloons
• ED Urgent:
1. Sterile OR basin (ED Acute)
2. Pack of sterile OR towels
3. Half sheet
4. 3x 60cc GU Guns (non-leur lock)
5. 30cc syringe if 30cc balloon on 3-way
6. NON-REFLUXING drainage bag – DO NOT use any other kind
7. Cysto irrigation tubing carton
8. Sterile 4x4 box
9. Betadine bottle
10. 2x 1L normal saline bottles
11. Sterile gloves
12. Safety glasses
13. 2x bags of 2L NS (ED/E6/OR)
• If irrigating on floor, may need gather supplies from different areas

**If latex allergic:

• Grab assortment of 2-way silicone catheters and sterile scissors. Cut off the end so
outlet is much bigger.
• 18Fr 3-way catheter is largest in the silicone variety which is unfortunate (make sure you
get all the clot out)
• Non-latex gloves

Updated 6/2018 61
Bedside cystoscopy Michelle Kim, MD, PhD

Transurethral cystoscopy is a method of direct visualization of the bladder and urethra. It is

performed using a lighted fiberoptic tube called a cystoscope. The cystoscope has a self-contained
optical lens system that provides a magnified, illuminated view of the urethra, the section of the
urethra surrounded by the prostate gland (prostatic urethra), the bladder, and the openings of the
ureters into the bladder (ureteral orifices). Cystoscopes are either rigid or flexible. Rigid
cystoscopes are long, straight, and stiff instruments. Flexible cystoscopes are also long, but they
can be gently bent and curved. Flexible cystoscopes cause less discomfort to the individual and
can be used at the bedside, in an office setting, or in an operating room. Flexible cystoscopes are
also used when the individual cannot be positioned with the legs up in stirrups (lithotomy
position), is positioned flat on the back (supine).

Indications for bedside cystoscopy

• Trauma while inserting a catheter per urethra leading to significant bleeding, false
passages, perforations, edema
• Difficulty in passing a catheter per urethra due to urethral strictures, bladder neck
contractures, prostate cancer
• Stent removal
• Hematuria workup

How to set up a flexible cystoscopy cart

Notify the Grey Desk (Bigelow 3 OR) that you would like to use the cysto cart and you are planning
to take it out of the OR. The cysto cart belongs to the OR and is stored in the Jackson Supply
Room. Someone will bring the cart to you. The cart contains all the supplies that you will need to
perform flexible cystoscopy. The cart gets restocked at least once daily. The items on the cart are
standardized and have been chosen with the approval of the residents.

When you have completed the procedure, return the cart to the Grey Desk so that it can be
returned to its holding area. Fill out the provided supply sheet to indicate the items that have
been used and need to be replaced.

Performing the procedure

• The first few times you do a flexible cystoscopy, it will be with the assistance of a more
senior resident. During those times, pay attention to how the resident sets up the room
and prepares the patient. The more technical aspects of the procedure will come with
practice.
• Details of the procedure are explained to the patient, and then informed consent is
obtained.

Updated 6/2018 62
 • Position the patient supine on his/her bed, uncover genitalia. Soak betadine solution in
pack of unclipped 4x4 sponges. Prep patient with solution in sterile fashion. Use a sterile
towel to prop up penis (male) to keep sterile.
• Use sterile half sheet/drape/gown to drape the patient from the pubic symphysis down to
feet. Use sterile area to connect cystoscope to NS irrigation tubing. Connect cystoscope to
light box. Open two 10-mL syringe and sterile 2% lidocaine gel (Urojets) and place them
on the sterile field.
• Instill 20 mL of lidocaine gel into the urethra. Place a finger on the meatus to help prevent
spillage of the anesthetic lubricant.
• Turn on NS irrigation and insert cystoscope into urethra. Keeping the lumen of the urethra
in the middle at all times, continue to advance the cystoscope until you enter the bladder.
If there is lot of bleeding, which obscures the vision, or if there is an area of resistance, the
bag of irrigating fluid (0.9% sodium chloride solution) is squeezed for a few seconds to
achieve clear vision and, thereby, enable safe passage of cystoscope through the urethra.
• If access needs to be obtained, a flexible guidewire is inserted through flexible cystoscope.
The tip of guide wire should be seen inside the bladder. The cystoscope is then withdrawn
while advancing the guide wire further thus ensuring that the tip of guide wire stays inside
the bladder. Then a Foley catheter, which has open proximal end, is threaded over the
guide wire. When the Foley catheter is inserted into the urinary bladder, urine will start
draining from the Foley catheter. After inflating the balloon of Foley catheter, the guide
wire is removed. Thus flexible cystoscopy ensures safe insertion of a Foley catheter into
the urinary bladder in patients with urethral trauma or false passages.

Updated 6/2018 63
Priapism – Corporal Irrigation Michael T. Grant, MD

Supplies needed for corporal irrigation

1. ABG kit
2. Consent form
3. 1% Lidocaine (no epinephrine)
4. Blunt tip or < 18g needle (to draw up lidocaine)
5. Long 22g or 23g needle (for penile block)
6. 1% Phenylephrine 10mg/mL
7. 6 – 60mL Luer lock syringes
8. 1 - 30mL Luer lock syringe
9. 14 gauge angiocath
10. IV extender
11. 3-way stop-cock valve
12. 1L worth of NS (e.g. 250mL bottle x4)
13. 2 blue sterile bowls (mark one of them as “phenylephrine solution”) 14. Coban wrap

Corporal Irrigation Steps

1. Get consent for irrigation

2. IV pain medication
3. Send cavernosal blood gas STAT...if ischemic, then continue
4. Have patient put on telemetry
5. Penile block - inject 5mL of lidocaine at 10 o’clock and 2 o’clock just under pubic bone.
You can also do a circumferential block using another 10mL of lidocaine
6. Mix 1mL of Phenylephrine with 50mL of NS in a sterile blue bowl to create concentration
of 200mcg / mL (acceptable rate = 100-500 mcg / mL). Draw up into 30mL syringe.
7. Insert 14-guage angiocath laterally into the corpora. Hook up IV extender and 3-way
stop-cock valve.
8. Begin with aspiration. If difficult to aspirate thickened blood, proceed with irrigation.
9. Irrigate with NS using 60cc syringes. Repeat until irrigant moves in and out more easily
10. Using 30cc syringe of phenylephrine solution, inject 1 cc (up to 500 mcg per injection)
every 3-5 minutes until detumescence is achieved.
11. Repeat irrigation and phenylephrine injections for up to 1 hour. Otherwise move on to
shunt procedures
12. Mummy wrap penis at conclusion with Coban

Updated 6/2018 64