LO Kidney Week 5

1. Describe the abnormality associated with the common congenital

anomalies of the genitourinary tract, specifically congenital obstruction,
vesicoureteral reflux, cryptochidism, hypospadias

Vesicoureteral Reflux
Vesicoureteral reflux (VUR) is defined as the retrograde flow of urine from the bladder into the
ureter and, in many cases, the renal pelvicalyceal system. This condition is considered problematic
because it facilitates propulsion of bacteria toward the kidneys, which can cause recurrent
pyelonephritis, renal scarring, and eventual renal dysfunction.

• Pathogenesis

Normal ureteral continence relies on a valve mechanism formed as the ureter courses
between the bladder mucosa and detrusor muscle before terminating at the ureteric
 orifice. When the bladder contracts, compression of the intramural segment of each ureter
prevents the retrograde flow of urine. Primary reflux occurs when the ureterovesical
junction (UVJ) is abnormal. In non-refluxing UVJs, the length of the ureter’s intramural
segment is at least five times the ureteral diameter. In refluxing UVJs, in contrast, the
intramural segment is too short or, less often, the ureteral diameter is too wide. As a result,
the valve mechanism is inadequate to prevent the reflux of urine during bladder
contraction. Although there is a clear genetic basis for VUR, as evidenced by high rates of
concordance among monozygotic twins, the genes that modulate UVJ structure have not
been identified. Secondary reflux occurs when there are very high filling pressures in the
bladder, which overwhelm otherwise normal ureterovesical junctions. In male infants, a
common cause is posterior urethral valves, which cause congenital bladder outlet
obstruction. Other causes include neurogenic bladder, dysfunctional voiding, and
ureterocele. Although VUR is not itself a risk factor for lower urinary tract infection, it does
permit the passage of bacteria from the bladder to the kidneys. Over time, repeated
episodes of pyelonephritis can result in renal scarring and dysfunction, especially if
infections occur in the first year of life. In contrast, the reflux of sterile urine does not
appear to cause renal scarring at any age. Of note, VUR also appears to be associated with
a variable degree of renal dysplasia that is unrelated to infection. Indeed, both VUR and
renal dysplasia could be expected to result from an abnormally caudal position of the
ureteric bud on the mesonephric duct because this arrangement would cause both (1)
suboptimal interaction between the ureteric bud and metanephric mesenchyme, as well
as (2) a short intramural course for the ureter.

• Clinical Manifestations

o First suspected: Prenatal with hydronephrosis

o Persistent hydronephrosis in postnatal infants
o Male child has a UTI
 o Female child less than 5 years of age has a UTI or a female child of any age has a
febrile UTI
• Diagnosis
o Lab Studies
▪ Urinalysis and urine culture: indicated for all children with hydronephrosis
to know whether infection or not
▪ Renal function test : Serum creatinine, urea, and electrolytes
o Imaging
▪ Ultrasound
• Renal ultrasound is neither a sensitive nor specific modality for
diagnosing VUR. However, any abnormality detected on renal
ultrasound in a child with febrile UTI is an indication to perform a
voiding cystourethrogram. Routine antenatal ultrasound can also
detect fetal hydronephrosis, which can occur secondary to VUR.
Hydronephrosis with undilated (normal) ureters is diagnostic of
ureteropelvic junction obstruction.
▪ Gold standard: voiding cystourethrogram (VCUG)
• In a VCUG, the bladder is instilled with contrast and examined under
fluoroscopy while the patient voids. The diagnosis of VUR is
established if contrast is seen entering one or both ureters. The
severity of the reflux can be classified into one of five grades based
on the International Reflux Grading system.
• Treatment
o Conservative
▪ Indications: VUR grades I–III in children < 5 years of age
▪ Correction of voiding dysfunction: behavior modification (e.g., timed
voiding (every 3 hours), prevention of constipation)
▪ Long-term prophylactic antibiotics
Children > 3 months: trimethoprim-sulfamethoxazole,
nitrofurantoin
Infants < 2 months: amoxicillin
▪ Close surveillance: urinalysis, renal imaging
o Surgical
▪ Indications
VUR ≥ grade IV
Bilateral grade III VUR, especially in children > 6 years
Worsening renal function/breakthrough urinary tract infections
despite prophylactic antibiotics
▪ Subureteric transurethral injection (STING procedure) [11]
Cystoscopy-guided injection of dextranomer/hyaluronic acid below
the mucosa of the ureterovesical junction keeps the intravesical
ureter in place, alters its angle, and, thereby, corrects the VUR.
Day-care procedure
Success rates of up to 90%
▪ Surgery: ureteral reimplantation (ureteroneocystostomy)

• Complications
o Infections
▪ Urosepsis
▪ Pyelonephritis
▪ Perinephric abscess
 o Renal complications
▪ Renal scarring
▪ Chronic kidney disease

Congenital Obstruction (Ureteropelvic Junction Obstruction)

Obstruction of the ureteropelvic junction (UPJ), located where the renal pelvis meets the
proximal ureter, typically reflects congenital abnormalities of either the ureter or surrounding
structures. These are often detected during routine ultrasound examination of a growing fetus.
The incidence of congenital UPJ obstruction is approximately 1:1000, with a slight male and left-
sided predominance. In 10% to 40% of cases, the obstruction is bilateral.

• Pathogenesis

There are multiple possible causes of congenital UPJ obstruction, which include:

▪ A congenital lack of spiral muscle around the affected segment of the

renal pelvis
▪ Developmental failure to recanalize the ureteral lumen
▪ Ureteral kinking that results from persistence of ureteral folds, which
normally disappear during development
▪ Insertion of the ureter superior to the most dependent portion of the
renal pelvis, thereby limiting drainage
▪ Direct compression by accessory vessels crossing from the renal artery or
aorta to the lower pole of the kidney (i.e., extrinsic obstruction)
 ▪ Acquired UPJ obstruction, in contrast, may occur during childhood or
adulthood, typically in the setting of stones, chronic inflammation with
stricture formation, polyps, malignancy, or surgical insult.

Intrinsic : Malformation of the smooth muscle of a ureteral segment and

consecutive impairment of peristalsis (functional stenosis)

Extrinsic : Aberrant renal pole artery causing proximal ureteral obstruction

• Clinical Manifestations
o Newborns and infants
▪ Palpable upper abdominal mass
▪ Failure to thrive (inadequate growth of a child based on age
▪ Recurrent pyelonephritis
 o Children and Adults
▪ Flank pain or upper abdominal pain that may be triggered or worsened
during states of increased diuresis (e.g., after caffeine or alcohol
consumption).
▪ Nausea/vomiting
▪ Recurrent pyelonephritis
▪ Hematuria

In older children and adults, undiagnosed congenital or acquired UPJ

obstructions may cause intermittent, severe flank pain following increased
fluid or diuretic intake. In addition, patients may experience hematuria after
mild trauma, the theory being that distention of the renal pelvis causes
mucosal vessels to become more friable.

• Diagnosis
o Ultrasound: hydronephrosis
▪ In some circumstances, it may be difficult to distinguish the dilated calices
seen in hydronephrosis from the large intraparenchymal cysts seen in
multicystic dysplastic kidney (MCDK).
Radiographic continuity between the dilated regions suggests
hydronephrosis, while dilated regions that are distinctly separate favors
MCDK.
o IV urography: excludes vesicoureteral reflux and assesses ureteral patency
o MAG3 renal radionucleotide scan
▪ In adults and children older than 3 months of age, diuretic renography
using 99mTc-MAG3 nuclear tracer should be performed once negative
urine cultures have been obtained because it permits precise
measurement of renal drainage.
 ▪ Nuclear scanning may help further differentiate the two conditions
because radiotracer will concentrate in the hydronephrotic kidney, which
retains some function, but not in the MCDK, which lacks function.

If a crossing vessel is suspected, duplex ultrasonography, CT angiography, or magnetic

resonance angiography may help guide further management.

• Treatment
o Observation : asymptomatic, mild cases
o Surgery : symptomatic patients or those with > 40% loss of renal function
▪ Anderson-Hynes pyeloplasty : open or laparoscopic resection of the
obstructed segment and anastomosis of the ureter to the remaining renal
pelvis
Cryptochidism

Failure of one or both testicles to descend to their natural position in the scrotum.

• Pathogenesis

A normal hypothalamic-pituitary-gonadal axis is a prerequisite for normal testicular

descent. Birth weight appears to be the main risk factor for undescended testes, followed
by family history. Absence of an appendix testis has been linked to abdominal and
cryptorchid testes especially if located proximal to the external ring. The exact role of the
appendix testis in testicular descent is unclear.

In full-term infants, the cause of cryptorchidism often cannot be determined, making this
a common but sporadic, idiopathic birth defect. It is thought that genetics, combined
with maternal and environmental factors, may disrupt hormones and physical changes
that influence testicular development and descent.

Possible underlying risk factors include:

o Premature infants born before the descent of the testicles

o Small for gestational age infants

o Smaller placental weight

o Chemicals endocrine disruptors may interfere with normal fetal hormone balance

o Maternal obesity

o Maternal diabetes

o Maternal exposure to DES

o Pesticides

o Alcohol consumption during pregnancy (5 or more drinks per week, 3x increase)

o Cigarette smoking

o Family history

o Cosmetics use

o Exposure to phthalate (DEHP)

o Ibuprofen

o Preeclampsia (The more severe the preeclampsia, the greater the risk of
cryptorchidism)

o Congenital malformation syndromes - Down syndrome, Prader–Willi syndrome,

and Noonan syndrome

o Persistent Mullerian Duct Syndrome

o In vitro fertilization

One contributing mechanism for the reduced function of cryptorchid testes is

temperature. It is also likely that transient hormone deficiencies may lead to a lack of
testicular descent and impair the development of spermatogenic tissue.
• Clinical Manifestations
o Palpable (80% of cases) : testicle cannot be manually manipulated into the
scrotum
o Non-palpable : may be intra-abdominal or absent
• Types
o Inguinal testis : The testicle is located between the external and
internal inguinal ring, preventing adequate mobilization (90% of cases).
o Intra-abdominal testis : The testicle is located proximal to the internal
inguinal ring.
o Ascending testes
▪ Testicular retraction into the scrotal pouch is possible.
▪ However, the testes immediately retract into the groin after manipulation.
• Diagnosis
o Primarily a clinical diagnosis
o Laboratory tests
▪ Testosterone
• Bilateral cryptorchidism: ↓ testosterone levels
• Unilateral cryptorchidism: normal levels (normal Leydig cell
function)
▪ ↓ Inhibin B (A hormone produced by Sertoli cells (spermatogenesis) in
males and ovarian granulosa cells in females that suppresses the release
of follicle stimulating hormone (FSH))
▪ ↑ FSH (stimulates the maturation of germ cells in both men and women),
↑ LH (stimulates testicular Leydig cells to synthesize testosterone)
• Treatment
o Cryptorchidism typically resolves without treatment via spontaneous descent of
testicles by 6 months of age.
o Persistent cases require surgery, which should be performed between 6 and 18
months of age.
 ▪ Orchidopexy
• Exposure and fastening of the testicle to the scrotum
• Open/laparoscopic orchidopexy is used when testes are not
palpable in the scrotum.
▪ Orchiectomy: in cases of nonviable testicular remnants or late discovery of
undescended testicle (> 2 years)
o Close urological monitoring and early treatment are necessary in individuals with
an increased risk of testicular cancer and infertility.
• Complications
o Testicular cancer (germ cell tumors)
o Infertility: higher temperature of the abdominal cavity is suboptimal for
spermatogenesis → oligospermia → infertility
o Testicular torsion
o Inguinal hernia
2. Describe the differential diagnosis of the common causes of hematuria
based on either etiological or anatomic considerations
As a first step, a history is taken to rule out causes that do not require treatment, such as (previous) urinary
tract infections, menstruation, strenuous sport activity, or medical interventions in the urinary tract:
Patients with a history of any of these are excluded from further investigation.

If the history is negative, indicators of a nephrological cause are sought, usually by testing for albuminuria,
sediment testing to assess red blood cell morphology, and measuring blood pressure and renal function.
In addition to a detailed history and physical examination, it is important to distinguish between
glomerular and non-glomerular hematuria.

Glomerular hematuria : Brown-colored urine, RBC casts, and dysmorphic (small, deformed,
misshapen, sometimes fragmented) RBCs and proteinuria.
Nonglomerular hematuria : Reddish or pink urine, passage of blood clots, and eumorphic (normal-
sized, biconcavely shaped) erythrocytes
If no sign of glomerular kidney disease is found, further urological investigation with imaging of the upper
urinary tract and cystoscopy is recommended on the basis of a further risk calculation.

Hematuria that causes no symptoms and is clearly of glomerular origin makes serious urological disease
unlikely and generally requires no further urological diagnostic investigation. Marked albuminuria (>500
mg/24 h) tends to indicate a glomerular cause of the blood in the urine. However, in a patient with known
proteinuria and no previous recorded history of hematuria, it is important to exclude a urological cause.

Hematuria associated with renal colic suggests a ureteral stone, although a clot from a bleeding renal
tumor can cause the same type of pain. Hematuria is not uncommonly associated with nonspecific,
tuberculous, or schistosomal infection of the bladder. The bleeding is often terminal (bladder neck or
prostate), although it may be present throughout urination (vesical or upper tract).

Stone in the bladder often causes hematuria, but infection is usually present, and there are symptoms of
bladder neck obstruction, neurogenic bladder, or cystocele. Dilated veins may develop at the bladder neck
secondary to enlargement of the prostate.
These may rupture when the patient strains to urinate, resulting in gross or microscopic hematuria.
Hematuria without other symptoms (silent hematuria) must be regarded as a symptom of tumor of the
bladder or kidney until proved otherwise. It is usually intermittent; bleeding may not recur for months.
Because the bleeding stops spontaneously, complacency must be condemned.

Less common causes of silent hematuria are staghorn calculus, polycystic kidneys, benign prostatic
hyperplasia, solitary renal cyst, sickle cell disease, and hydronephrosis. Painless bleeding is common with
acute glomerulonephritis. Recurrent bleeding is occasionally seen in children suffering from focal
glomerulitis. Joggers and people who engage in participatory sports frequently develop transient
proteinuria and gross or microscopic hematuria.

Alur Cek Imaging

3. Describe findings on history and physical exam that may help define
the source of hematuria, specifically :

a. Upper tract vs Bladder vs Prostate vs Urethra

History Taking
Hematuria is manifested as partial (initial, terminal) or total (present throughout urination) is often of
help in identifying the site of bleeding. Initial hematuria suggests an anterior urethral lesion (eg, urethritis,
stricture, meatal stenosis in young boys). Terminal hematuria usually arises from the posterior urethra,
bladder neck, or trigone. Among the common causes are posterior urethritis and polyps and tumors of
the vesical neck. Total hematuria has its source at or above the level of the bladder (eg, stone, tumor,
tuberculosis, nephritis)
Most patients with macroscopic haematuria will require cystoscopy and imaging to exclude a post renal
cause (including malignancy) for their haematuria. As such the primary referral route should be to
Urology. Referral to nephrology will be considered within the secondary care setting in patients with
significant proteinuria (greater than 2+), abnormal renal function (eGFR < 60mL/min/1.73m2 ) or
imaging findings suggestive of primary renal disease.

b. Genitourinary specific or systemic

History Taking
Genitourinary specific :
1] Family history of renal disease; hereditary nephritis, polycystic kidney disease, sickle cell disease
2] Nephrotoxic drugs

Systemic :
1] Constitutional symptoms (weight loss, fevers, sweats, malaise, arthralgias), suggesting systemic
conditions including vasculitis
2] Persistent exercise induced haematuria
In general, if the urine clears 72 hours after exercise, there is no need to further investigate.
However, some causes do need to be investigated, particularly if the blood in the urine keeps
appearing, or does not clear after 72 hours. Sometimes, the breakdown products of red blood
cells and muscles may appear in urine, making the urine appear much darker, and this may be
mistaken for actual blood. Some foods may color the urine reddish, and some medications, such
as blood thinners, may lead to actual blood in the urine. For most cases of exercise-induced
hematuria, the causes are related to the intensity and duration of activity, as well as the
hydration status of the athlete. Longer and more intense events have been known to more likely
cause hematuria. It is most common in runners, especially those running more than 10,000
meters. Sometimes, hematuria is related to a traumatic injury, such as a direct blow or a fall.

Important historical findings include fever, back pain, dysuria, urgency, frequency (urinary tract
infection); renal colic or previous nephrolithiasis (renal stone disease); weight loss, especially with
abdominal pain (renal cell carcinoma); or weight loss with a significant smoking history, analgesic abuse,
or exposure to industrial dyes (bladder carcinoma); recent sore throat or skin infection, edema,
hypertension (glomerulonephritis); recent back, abdominal, or urethral injury or vigorous exercise
(trauma); history of heart murmur with recent dental or genitourinary manipulation (endocarditis); or a
history of bleeding from other sites, a previous bleeding disorder, or family history of a bleeding
disorder (systemic coagulopathy). A careful drug history should be taken with special attention to
analgesics (papillary necrosis), cyclophosphamide (hemorrhagic cystitis), anticoagulants, and drugs
known to cause acute interstitial nephritis.
 Physical Examination
• Measurement of the blood pressure (with an appropriately sized cuff)
• Evaluation for the presence of periorbital puffiness or peripheral edema
• Detailed skin examination to look for purpura and/or petechiae
• Abdominal examination to look for palpable kidneys
• Cardiac murmurs, rales, costovertebral angle tenderness, abdominal tenderness, and abdominal
masses
• Careful examination of the genitalia for possible sites of bleeding around the urethral meatus in
both sexes or vaginal bleeding in the female.
• Detailed ophthalmologic evaluation (in familial hematuria)
• Skin rashes and arthritis can occur in Henoch-Schönlein purpura and systemic lupus
erythematosus.
• Joint pains, skin rashes, and prolonged fever in adolescents suggest a collagen vascular disorder.
• Recent throat or skin infection may suggest postinfectious glomerulonephritis.
• Fever, abdominal pain, dysuria, frequency, and recent enuresis in older children may point to a
urinary tract infection as the cause.
• Recent trauma to the abdomen may be indicative of hydronephrosis
4. Describe the most common findings on history or exam (signs) and
patient complains (symptoms) at presentation of the following clinical
problems :

a. Renal tumors

The major presenting symptom of an upper tract urothelial carcinoma is gross or microscopic
hematuria. If there is obstruction of the ureter, dull flank pain may also occur.

- Blood in the urine (hematuria)

- Low back pain on one side (not caused by injury)
- A mass (lump) on the side or lower back
- Fatigue (tiredness)
- Loss of appetite
- Weight loss not caused by dieting
- Fever that is not caused by an infection and that doesn’t go away
- Anemia (low red blood cell counts)
- In the testicles, a rapid development of a cluster of enlarged veins, known as a
varicocele, around a testicle, particularly the right testicle, may indicate that a large
kidney tumor may be present
b. Bladder tumors

Approximately 85% of patients with bladder cancer have painless gross hematuria. In adults, this
symptom should be considered highly suspicious for cancer unless there is compelling evidence
that the blood is of glomerular origin (i.e., large numbers of red blood cell casts or dysmorphic
red blood cells are seen). 20% to 30% of patients also experience bladder irritability, urinary
frequency, urgency, and/or dysuria. More advanced bladder cancers may rarely be associated
with flank pain from ureteral obstruction or lower extremity edema from lymphatic or venous
obstruction. On physical examination, a bimanual examination (rectoabdominal in men,
vaginoabdominal in women) may reveal a palpable mass in advanced cases; however, most
examinations are unremarkable.
c. Prostate cancer

Symptoms of local disease

In the pre-PSA era, patients with prostate cancer commonly presented with symptoms that included
urinary complaints or retention, back pain, and hematuria. Currently, with PSA screening, most prostate
cancers are diagnosed at an asymptomatic stage. When symptoms do occur, diseases other than
prostate cancer may be the cause. For example, urinary frequency, urinary urgency, and decreased urine
stream often result from benign prostatic hyperplasia.

Symptoms of advanced disease

Advanced prostate cancer results from any combination of lymphatic, hematogenous, or contiguous
local spread. Skeletal manifestations are especially common because prostate cancer has a strong
predilection for metastasizing to the bone.

Manifestations of metastatic and advanced prostate cancer may include the following:

Weight loss and loss of appetite

Anemia

Bone pain, with or without pathologic fracture

Neurologic deficits from spinal cord compression

Lower extremity pain and edema due to obstruction of venous and lymphatic tributaries by nodal
metastasis

Uremic symptoms can occur from urethral obstruction caused by local prostate growth or
retroperitoneal adenopathy secondary to nodal metastasis.
d. Scrotal tumor

- Benjolan yang tidak nyeri atau bengkak di salah satu testis. Jika ditemukan lebih awal, tumor
testis mungkin seukuran kacang polong atau kelereng, tetapi bisa tumbuh jauh lebih besar.
- Pain, discomfort, or numbness in a testicle or the scrotum, with or without swelling.
- Perubahan rasa testis atau rasa berat di skrotum. Misalnya, 1 testis mungkin menjadi lebih
kencang dari testis lainnya. Atau kanker testis dapat menyebabkan testis membesar atau
mengecil.
- Nyeri tumpul di perut bagian bawah atau selangkangan
- Sudden buildup of fluid in the scrotum
- Nyeri atau pertumbuhan payudara. Meski jarang, beberapa tumor testis membuat hormon yang
menyebabkan nyeri payudara atau pertumbuhan jaringan payudara, suatu kondisi yang disebut
ginekomastia.
- Nyeri punggung bawah, sesak napas, nyeri dada, dan dahak atau dahak berdarah dapat menjadi
gejala kanker testis stadium lanjut.

Pembengkakan pada salah satu atau kedua tungkai atau sesak napas akibat bekuan darah dapat menjadi
gejala kanker testis. Bekuan darah di vena besar disebut trombosis vena dalam atau DVT. Gumpalan darah
di arteri di paru-paru disebut emboli paru dan menyebabkan sesak napas. Untuk beberapa orang muda
atau paruh baya, mengembangkan bekuan darah mungkin merupakan tanda pertama dari kanker testis.
5. Explain the advantages and disadvantages of the various radiological
imaging techniques as applied to the urinary tract, including :

a. Non-contrast Ultrasound

b. Contrast enhanced IVP

c. Computed tomogram scan

d. Magnetic resonance imaging

Specific

examination: anterograde pyelography, retrograde pyelography, etc

6. Recognize, identify and describe the :

a. Normal radiography anatomy of the genitourinary tract

b. Radiographic features of renal masses, including cysts

Basic Principle :
c. Radiographic features of renal or ureteral calculi (stones)
Features:

Plain radiograph

Calcium-containing stones are radiopaque:

• calcium oxalate +/- calcium phosphate

• struvite (triple phosphate) - usually opaque but variable

• pure calcium phosphate

Lucent stones include:

• uric acid

• cystine
• medication (indinavir is best known) stones

• pure matrix stones (although may have a radiodense rim or center 15)

Fluoroscopy

Intravenous urography (IVU) is a traditional radiographic study of the renal parenchyma,

pelvicalyceal system, ureters, and the urinary bladder. It involves the administration of
intravenous contrast. This exam has been largely replaced by non-contrast CT.
Ultrasound

Ultrasound is frequently the first investigation of the urinary tract, and although by no

means as sensitive as CT, it is often able to identify calculi. Small stones and those close
to the corticomedullary junction can be difficult to reliably identify. Ultrasound compared

to CT KUB reference showed a sensitivity of only 24% in identifying calculi. Nearly 75% of
calculi not visualized were <3 mm 13. Features include 7:

• echogenic foci

• acoustic shadowing
• twinkle artifact on color Doppler

• color comet-tail artifact 9

Pulsed wave (PWD) and color flow Doppler (CFD) are further sonographic modalities that

may act as a diagnostic aid, and assess for the presence of complications;

• ureteric jets in obstructive uropathy tend to be shorter, slower, and occur less often
o suggested cutoff values vary; the combination of fewer than 1.5 jets per

minute, with peak velocities below 19.5 cm/s and jet durations less than 2.5
seconds have specificities ranging between 87 and 97%

• the renal resistive index (RI) is significantly higher in obstructed kidneys

o contralateral unaffected renal RI comparison useful

o elevation in RI may precede pelvicalyceal dilation

CT

On CT almost all stones are opaque but vary considerably in density.

• calcium oxalate +/- calcium phosphate: 400-600 HU

• struvite (triple phosphate): usually opaque but variable

• pure calcium phosphate: 400-600 HU

• uric acid: 100-200 HU

• cystine: opaque

Two radiolucent stones are worth mentioning :

• medication (protease inhibitor (indinavir)) stones

o radiolucent and usually undetectable on non-contrast CT

o characterized on delayed phase as a filling defect in the ureter

• pure matrix stones

99% of renal tract calculi are visible on a non-contrast CT. Given that one of the

commonest sites for a stone to become lodged is the vesicoureteric junction, some
centers perform the study in the prone position to establish if the stone is retained within

the intravesical component of the ureter or has already passed into the bladder itself.

Dual-energy CT

Dual-energy CT is a technique allowing the composition of the calculus to be determined,

by assessing stone attenuation at two different kVp levels. Each CT vendor has its own

algorithms for the use of dual-energy CT for assessing stone composition. Dual-energy
CT may be useful in detecting stones concealed by the opacification of the collecting

system. Dual-energy CT has also been shown to predict the success of extracorporeal
shock wave lithotripsy.
7. Describe a cost effective and differential driven diagnostic approach to
the patient with hematuria including the indications for and cautions in the
use of each radiologic imaging

8. Describe and understand to evaluate and manage patient with

urological trauma

9. Describe about male reproductive and sexual function

10. Describe the indications for urological consulation and possible

cystoscopy/ ureteroscopy
Metastatic
LO Tutorial 1

1. Penyebab painless hematuria (dari obat yang bisa buat urin warna merah,
obat yang mengganggu kerja ginjal sehingga bisa hematuria, faktor
makanan, dll) , cari tahu detail penyebab urin jadi merah

- Described in WO

2. Glomerular & non glomerular hematuria

- Described in WO

3. Pendekatan diagnosis hematuria (PF findings & history taking)

- Described in WO

4. Pemeriksaan penunjang untuk diagnosis curiga Ca & metastasis

Tumor markers (biologic markers) are substances produced by cancer cells that are found either in or on
the tumor cells or in the blood, spinal fluid, or urine. Some tumor markers have been known for many
decades. For diseases associated with a tumor marker, there is indeed a “blood test for cancer.” Tumor
markers include hormones, enzymes, genes, antigens, and antibodies. For example, the adrenal medulla
normally secretes the catecholamine epinephrine (adrenaline). Benign tumors of the adrenal medulla can
produce catechol amines in vast excess, leading to rapid pulse, high blood pres sure, sweats, and
tremors. Elevated blood or urine levels of catecholamines in someone with this set of symptoms strongly
suggest the presence of an adrenal medullary tumor (pheo chromocytoma). Liver and germ cell tumors
secrete a protein known as alpha fetoprotein (AFP) into the blood, and prostate tumors secrete prostate
specific antigen (PSA) into the blood. These tumor markers can be used in three ways: (1) to screen and
identify individuals at high risk for cancer; (2) to help diagnose the specific type of tumor in individuals
with clini cal manifestations relating to cancer, as in adrenal tumors; and (3) to follow the clinical course
of cancer. For example, a falling PSA after therapy for prostate cancer indicates successful treat ment,
and a later rise in the PSA may indicate a recurrence. A significant problem in diagnosing cancer using
tumor marker assays is that nonmalignant conditions also can produce tumor markers. The presence of
an elevated tumor marker therefore may suggest a specific diagnosis, but it is not used alone as a
definitive diagnostic test. Identification of ideal sensitive and specific tumor markers that are elevated
early in the course of common cancers remains a high prior ity because the early detection of cancer
often improves the treatment outcome.