Oxford American Handbook of

Urology

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Oxford American Handbook of Urology

3

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First published 2011

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Library of Congress Cataloging-in-Publication Data

Oxford American handbook of urology / edited by David M. Albala ... [et al.] ; with John Reynard, Simon Brewster, Suzanne Biers.

p. ; cm.—Other title: Handbook of urology Includes bibliographical references and index.

ISBN 978-0-19-537139-0

1. Urology—Handbooks, manuals, etc. 2. Urinary organs—Diseases—Handbooks, manuals, etc. I. Albala, David M. II. Title: Handbook of urology.

[DNLM: 1. Urologic Diseases—Handbooks. 2. Female Urogenital Diseases— Handbooks. 3. Male Urogenital Diseases—Handbooks. WJ 39 O973 2011]

9 8 7 6 5 4 3 2 1

Printed in China on acid-free paper

This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. Oxford University Press and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material, including without limitation that they make no representation or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publishers do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.

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vii

Preface

The goal of the Oxford American Handbook of Urology is to create a concise source of clinical information for medical students and physicians in training. This Handbook primarily presents the nonsurgical aspects of urolo- gy—the information needed for making a rapid diagnosis and determining the proper initial treatment course amid the confines of a busy clinical practice. It is meant to be a practical pocket reference, not an exhaustive treatise on urology.

As we witness the rapid pace of advancement in urological surgery, it becomes ever more difficult for any urologist to stay current in all areas of our specialty. The Handbook aims to provide the reader with an efficient information source that will be helpful in guiding effective management of our growing population of urological patients.

The book is written for our patients, with appreciation for the many mentors from whom we have learned, and for the many students and residents we have been fortunate to train. It is adapted for the American practice of urology from the Oxford Handbook of Urology, published in the UK, and we thank John Reynard, Simon Brewster, and Suzanne Biers for their fine book and the opportunity to “Americanize” it.

We dedicate this book to our colleague and friend, John P. Stein, M.D., whose untimely death has left a large void in our specialty. He was an accomplished clinician, researcher, and teacher who will be sorely missed.

David M. Albala, M.D.

Allen F. Morey, M.D.

Leonard G. Gomella, M.D.

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Index 673

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xi

Detailed contents

1Significance and preliminary investigation of

Cystic renal disease: medullary sponge kidney (MSK) 336 Acquired renal cystic disease (ARCD) 338

Autosomal dominant (adult) polycystic kidney disease (ADPKD) 340

Vesicoureteric reflux (VUR) in adults 342

xvi DETAILED CONTENTS

Ureteropelvic junction (UPJ) obstruction in adults 346

Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation 348

Renal duplications 352

Kidney stones: epidemiology 356

Kidney stones: types and predisposing factors 358 Kidney stones: mechanisms of formation 360 Factors predisposing to specific stone types 362 Evaluation of the stone former 366

Kidney stones: presentation and diagnosis 368 Kidney stone treatment options: watchful waiting 370

Stone fragmentation techniques: extracorporeal lithotripsy (ESWL) 372

Intracorporeal techniques of stone fragmentation (fragmentation within the body) 374

Kidney stone treatment: flexible ureteroscopy and laser treatment 378

Kidney stone treatment: percutaneous nephrolithotomy (PCNL) 380

Kidney stones: open stone surgery 383

Kidney stones: medical therapy (dissolution therapy) 384 Ureteric stones: presentation 386

Ureteric stones: diagnostic radiological imaging 388 Ureteric stones: acute management 390

Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone 392

Ureteric stone treatment 394

Treatment options for ureteric stones 396 Prevention of calcium oxalate stone formation 398 Bladder stones 400

Management of ureteric stones in pregnancy 402

9Upper tract obstruction, flank pain, hydronephrosis 405

Hydronephrosis 406

Management of ureteric strictures (other than UPJ obstruction) 410

Pathophysiology of urinary tract obstruction 414 Physiology of urine flow from kidneys to bladder 416 Ureter innervation 417

xviii DETAILED CONTENTS

Bladder and sphincter behavior in the patient with neurological disease 506

The neuropathic lower urinary tract: clinical consequences of storage and emptying problems 508

Bladder management techniques for the neuropathic patient 510

Catheters and sheaths and the neuropathic patient 516

Management of incontinence in the neuropathic patient 518

Management of recurrent urinary tract infections (UTIs) in the neuropathic patient 520

Management of hydronephrosis in the neuropathic patient 522

Management of autonomic dysreflexia in the neuropathic patient 523

Ureteropelvic junction (UPJ) obstruction 549

Hypospadias 550

Normal sexual differentiation 552

Abnormal sexual differentiation 554

Cystic kidney disease 558

Exstrophy 560

Epispadias 562

Posterior urethral valves 564

DETAILED CONTENTS xix

Non-neurogenic voiding dysfunction 566

Nocturnal enuresis 568

Transurethral resection of bladder tumor (TURBT) 614

Optical urethrotomy 616

Circumcision 618

Hydrocele and epididymal cyst removal 620

Nesbit procedure 622

Vasectomy and vasovasostomy 624

Orchiectomy 626

Urological incisions 628

JJ stent insertion 630

Nephrectomy and nephroureterectomy 632

Radical prostatectomy 634

Radical cystectomy 636

Ileal conduit 640

Percutaneous nephrolithotomy (PCNL) 642

Ureteroscopes and ureteroscopy 646

Pyeloplasty 650

Laparoscopic surgery 652

xx DETAILED CONTENTS

Index 673

xxi

Symbols and

Abbreviations

ddecreased

iincreased

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Significance and preliminary investigation of urological symptoms and signs

Hematuria I: definition and types 2

Hematuria II: causes and investigation 4

Hematospermia 8

Lower urinary tract symptoms (LUTS) 10

Nocturia and nocturnal polyuria 14

Flank pain 16

Urinary incontinence in adults 20

Genital symptoms 22

Abdominal examination in urological disease 24

Digital rectal examination (DRE) 28

Lumps in the groin 30

Lumps in the scrotum 32

2CHAPTER 1 Preliminary investigation

Hematuria I: definition and types

Definition

Hematuria is the presence of blood in the urine.

Macroscopic (gross) hematuria is visible to the naked eye.

Microscopic or dipstick hematuria is when blood is identified by urine microscopy or dipstick testing, either in association with other urological symptoms (symptomatic microscopic hematuria) or during a routine medical examination (asymptomatic microscopic hematuria).

Microscopic hematuria is generally defined as 3 or more red blood cells (RBCs) per high-power field on a centrifuged specimen confirmed on 2 of 3 properly collected specimens.1,2

Urine dipsticks test for heme test for hemoglobin and myoglobin in the urine. The peroxidase-like activity of heme is used to catalyze reactions that produce colored compounds ranging from orange to green and dark blue. Dipsticks have a sensitivity of 90%, detecting 5 RBC/microliter. Confirm the presence of RBCs on a dipstick with microscopic exam to rule out a false positive.

•False positive urine dipstick: menstrual or dysfunctional uterine bleeding contamination, or the presence of myoglobinuria, free hemoglobin (e.g., transfusion reaction), bacterial peroxidases, povidone, hypochlorite

•False negative urine dipstick (rare): in the presence of reducing agents (e.g., ascorbic acid prevents the reagent strip oxidation reaction)

Is microscopic or dipstick hematuria abnormal?

A few RBCs can be found in the urine of normal people. The upper limit of normal for RBC excretion is 1 million/24 hours (as seen in healthy medical students). In healthy male soldiers undergoing yearly urine examination over a 12-year period, 40% had microscopic hematuria on at least 1 occasion and 15% on 2 or more occasions. Transient microscopic hematuria may occur following rigorous exercise or sexual intercourse.

A catheterized urinary specimen may be needed if a voided specimen cannot be reliably obtained (e.g., vaginal contamination, obesity, men with nonretractile foreskin [phimosis]).

Because the presence of RBCs in the urine is normal, a substantial proportion of patients with microscopic and dipstick hematuria and even macroscopic hematuria will have normal hematuria investigations (i.e., no abnormality is found). No abnormality is found in approximately 50% of subjects with gross hematuria and 70% with microscopic hematuria, despite full conventional urological investigation (urine cytology, cystoscopy, upper tract imaging).2

1 Grossfeld GD, Litwin MS, Wolf JS, et al. (2001). Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy—part I: definition, detection, prevalence, and etiology. Urology 57:599–603.

2 Khadra MH, Pickard RS, Charlton M, et al. (2000). A prospective analysis of 1930 patients with hematuria to evaluate current diagnostic practice. J Urol 163:524–527.

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4CHAPTER 1 Preliminary investigation

Hematuria II: causes and investigation

Any degree of confirmed hematuria should be evaluated, as it may be a sign of serious renal or urological disease, including malignancy (up to 20%). Gross hematuria is 5 times more likely to indicate a serious urological problem than is microscopic hematuria.

Common causes of hematuria

Although there is considerable overlap, hematuria in the clinical setting can be most broadly classified into surgical (urological) and medical causes, to help facilitate evaluation and management. Presence of white blood cells (WBCs) or bacteria, protein, red cell casts, or elevated serum creatine (Cr) and age of the patient may also be used to determine the cause.

Surgical (urological)

•Cancer: urothelial carcinoma or squamous cell carcinoma of the urethra, bladder, ureter, or renal pelvis; renal cell carcinoma; prostate cancer; other less common tumor types (sarcoma, adenocarcinoma)

•Stones (urolithiasis): kidney, renal pelvis, ureter, bladder

•Infection: pyelonephritis, cystitis, prostatitis, urethritis caused by agents such as bacterial, mycobacterial (TB), parasitic (schistosomiasis), fungal (Candida)

•Inflammation: cyclophosphamide cystitis, interstitial cystitis, radiation cystitis

•Trauma (blunt and penetrating): kidney, bladder, urethra (e.g., traumatic catheterization), pelvic fracture with urethral disruption

•Renal cystic disease: e.g., medullary sponge kidney

•Congenital abnormalities: vesicoureteral reflux, posterior urethral valves, ureteropelvic junction obstruction

Other urological causes include benign prostatic hyperpasia (BPH) (the large, vascular prostate), urethral stricture, fistula, urethral diverticulum, cystocele, recent surgical intervention, flank pain hematuria syndrome, and vascular malformations.

Medical (nephrological)

Medical causes of hematuria are more likely in children and young adults and if it is associated with proteinuria, elevated creatinine, or dysmorphic red cells/RBC casts. Glomerulonephritis is responsible for 30% of all cases of pediatric hematuria.

Renal parenchymal disease occurs with IgA nephropathy (Berger disease), postinfectious glomerulonephritis, and, less commonly, membranoproliferative glomerulonephritis, Henoch–Schönlein purpura, vasculitis, Alport syndrome, thin basement membrane disease, and Fabry disease.

Other medical causes include coagulation disorders (congenital, such as hemophilia) or anticoagulation therapy; sickle cell trait or disease; renal papillary necrosis; hypercalcuria; and vascular disease (e.g., emboli to the kidney with infarction and hematuria).

HEMATURIA II: CAUSES AND INVESTIGATION 5

Urological investigation of hematuria

In patients without evidence suggestive of medical renal disease, conventional urological investigation involves urine culture (if symptoms suggest urinary infection), urine cytology, cystoscopy, and upper tract imaging. Anticoagulation or aspirin use should never be automatically assumed to be the cause of hematuria. In these patients, malignancy can be seen in up to 24% and any hematuria should be evaluated.1

Patients with documented urinary tract infection (UTI) should be treated appropriately, and the urinalysis repeated approximately 4–6 weeks after treatment. If the hematuria resolves with treatment, no further evaluation is usually needed.2

In low-risk patients (<40 years without gross hematuria, no smoking history, no chemical exposure [i.e., benzenes or aromatic amines], no previous cyclophosphamide treatment, no irritative voiding complaints, no pelvic radiation, or no urological disease history), initial upper tract imaging is indicated, with further evaluation based on clinical findings.

In patients with high risk factors (high risk for urothelial carcinoma anywhere in the urinary tract), compete evaluation is indicated given the greater risk of malignancy.

Diagnostic cystoscopy

Typically this is carried out using a flexible, fiber-optic cystoscope in the outpatient setting with intraurethral lidocaine anesthesia.

•If radiological investigation demonstrates a lesion suggesting a urothelial carcinoma such as a bladder cancer, one may consider foregoing the flexible cystoscopy and proceed immediately to rigid cystoscopy and biopsy under anesthesia (transurethral resection of bladder tumor [TURBT]).

•Upper tract filling (renal pelvis, ureter) defects may also represent urothelial carcinoma or stones. Further intraoperative evaluation with retrograde pyelograms and ureteroscopy can be both diagnostic and therapeutic. However, the bladder must still be evaluated carefully with cystoscopy.

Should cystoscopy be performed in patients with asymptomatic microscopic hematuria?

The American Urological Association’s (AUA’s) Best Practice Policy on Asymptomatic Microscopic Hematuria recommends cystoscopy in all highrisk patients with microscopic hematuria (see risk factors on previous page).3 In asymptomatic, low-risk patients <40 years of age, it states that “it may be appropriate to defer cystoscopy,” but if this is done, urine should be sent for cytology.

1 Avidor Y, Nadu A, Matzkin H (2000). Clinical significance of gross hematuria and its evaluation in patients receiving anticoagulant and aspirin treatment. Urology 55(1):22–24.

2 Mariani AJ (1998). The evaluation of adult hematuria: a clinical update. In AUA Update Series 1998; Vol. XVII, lesson 24, pp. 185–192. Houston: AUA Office of Education.

3 Grossfeld GD (2001). Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association Best Practise Policy-Part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation and follow-up. Urology 57:604–610.