NEOPLASM IN THE GENITOURINARY TRACT

SURGERY SUBSPEC
DR CLAVERIA
AUG 18 2016

HISTOPATHOLOGY
A BLADDER TUMORS  Transitional cell CA (90%)
General Information:  papillary exophytic, sessile, ulcerated
nd
 Carcinoma in situ- flat lesion compared to the other
 2 most common in the GU tract groth of tumors
o 1st- prostate ca o Irrititative symptoms
Divided to:  Frequency
1) Transitional type of CA-illiothelial cancer  intermittency
o More common  nocturia
o 90% of all ca in the urinary bladder  Poor prognosis
o RF:  Higher tumor recurrence rate
 Cigarette smoking  Progress to invasive cancer
(napthylamines)  high grade tumor
 More than 60 y\o
 BCG intra-vesical therapy
 Sometimes as young as 20 y\o
 Occupational exposure- heavy
2) Non-Transitional Cell Carcinoma
metal industries-beta
1. Adenocarcinoma (2%)
napthelamines dye clothing
3 TYPES:
industrues
 Primary-arise in the inferior bladder area and the floor
 Cyclophospamide
 Urachal- arises at the dome of the bladder in
 Physical trauma to urothelium-
connection to the urachus
bladder stones
 Metastatic- come from other organs most commonly
 Chromosome 9 (long arm)
the small and large bowel
2. Squamous Cell CA
STAGING: (Jewett and Strong)
 (5-10%)
STAGE
 Commonly seen in patients with chronic mucosal
 A: Lamina propria (endothelium and mucosal
irritation secondary to kidney stones inflammation
layer)
infection or previous endoscopic intervention
 B1: Sup. Muscle
 B2: Deep muscle
Clinical Findings:
 C: Perivesical Fat
Symptoms:
 D: Contiguous Organ (prostate)
 Painless hematuria in 85-90%,
 Irritative voiding symptoms (CIS)

DIAGNOSIS:
1 urinalysis- presence of microscopic RBC in the urine
Positive if more than 5
Bladder Tumor
OTHER DIAGNOSTIC MODALITY USED: • SIGNS
◦ Patients with large-volume or invasive
1. Microscopic Cytology-
tumors may be found to have bladder
2. Flow Cytometry
wall thickening or a palpable mass
3. Excretory urography ◦ bimanual examination under anesthesia. If
4. Cystoscopy- to confirm mass
-directly visualize the inside of the bladder
5. Ultrasound -easiest
6. CT scan or MRI
*if mass is present- do direct cystoscopy

TREATMENT:
1. Intravesical Chemotherapy- done if in the low stages
after procedure
- insert catheter pour chemicals inside and
leave it for 30 min
a. Mitomycin
b. Thiotepa
Staging- important for management *drug a and b are both alkylating agents for DNA synthesis
*can be given immediately after cystoscopy
c. Doxorubicin- antibiotics
d. Bacillus Calmette-Guerin (BCG)- very careful in
handling because it can cause outright sepsis (active)
-given after 3-4 weeks

2. . Surgery
a. Transurethral resection or laser vaporization
b. Partial Cystectomy- mass in the dome
c. Radical Cystectomy- deep muscle involvement of
bladder ca
-removal of the entire urinary bladder
*males- remove bladder and prostate
*females- remove the bladder with the uterus the fallopian tube
and the others (NBLOC)
d. External Beam Irradiation- used for patients with

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metastasis esp bones abnormal mass palpated
e. Chemotherapy- not good surgical candidates- with *PSA- not specific for prostate ca
metastasis to the lungs etc  Seen in pts who has UTI chronic stones previous
 Usually use cysplatin based chemotherapy catheterization(anything that disrupts prostate tissue)
 *DRE- 15% chance of ca
B. TUMORS OF THE PROSTATE: *PSA- 30% chance of ca
1. . PROSTATE CANCER * combine- 50% chances of having ca
 Most common ca seen in the GUT *biopsy done after
General Information:
 Fibro-muscular tissue and glandular epithelial cells TREATMENT:
 20 grams -done management depending on the present health of the
 Prostate measurement patient
 Zonal anatomy • LOCALIZED
 Transition zone- BPH 1. Watchful waiting
 Peripheral zone- where prostate ca arise 2. Radical prostatectomy- primary treatment
Risk factors 3. Radiation therapy- if there is presence of pain
 increasing age secondary to bone metastasis
*prostate ca- slow growing
 family history
* problem: patient develop co morbidities like incontinence
 high dietary fat intake
• METASTATIC- need to decrease testosterone
 cadmium
1. Orchiectomy- to decrease testis
 previous vasectomy
2. Anti-androgen
PATHOLOGY:
3. LH-RH agonist – exerts negative feedback to pituitary
 95% → Adenocarcinoma o Initially causes elevation of testosterone
 Prostatic intraepithelial neoplasia (PIN) levels but later on testosterone will go
down
TNM STAGING FOR PROSTATE CANCER: o Advantage- remove the initial side effect of
T - PRIMARY TUMOR the patient having decrease in testosterone
 Tx- Cannot be assessed levels
 T0- No evidence of primary tumor 4. Estrogen
 Tis- Carcinoma in situ 5. . Chemotherapy
 T1a- ˂5% of tissue in resection for benign 6. Steroid (prednisone)
disease has cancer, normal DRE 7. Ketoconazole
 T1b- ˃5% of tissue in resection for benign disease has
cancer, normal DRE *RADICAL PROSTATECTOMY- not done if patient has metastasis
 T1c- detected from elevated PSA alone, normal DRE *decrease testosterone to prevent metastasis
and TRUS
C. PENILE TUMORS:
 T2a- tumor palpable by DRE or visible by TRUS on one  Appearance of difficult patients with anal carcinoma
side only, confined to prostate o Cauliflower with extensive inguinal
 T2b- tumor palpable by DRE or visible byTRUS on both inflammation and nodes
sides, confined to the prostate  Risk Factors
o Poor Hygiene (Uncircumcised)- most
 T3a- Extracapsular invasion on one or both sides common
 T3b- Seminal vesicle involvement o HPV infection
 Pre cancerous lesions (NTK!!)
 T4- Tumor directly extends to bladder neck sphincter, o . LEUKOPLAKIA
rectum, levator muscle or to pelvic side wall o BALANITIS XEROTICA OBLITERANS
N - REGIONAL LYMPH NODES o GIANT CONDYLOMA ACCUMINATA- HPV
 Nx- Cannot be assessed  Excision
 N0- No regional lymph node metastasis
 N1- Metastasis in regional LN Premalignant lesions
M - DISTANT METASTASIS STAGING:
 MX- Cannot be assessed *tunica albugenea- important
 M0- No distant metastasis -if there is infiltration of that part ca is in high stage
 M1a- Distant metastasis (non-regional lymph nodes)  STAGE 1: Tumors confined to glans or prepuce
 M1b- Metastasis to bone  STAGE 2: Tumors involving the penile shaft
 M1c- Metastasis to other sites  STAGE 3: Operable inguinal node metastasis
 STAGE 4: Tumor extending beyond the penile
*usually patients do not feel any pain shaft; inoperable inguinal or distant
DRE- done annually for detection
CLINICAL FINDINGS:
 Most patients with early prostate cancer are
asymptomatic
 Metastatic disease to the bones can cause bone pains
 DRE should be done for possible Ca
 PSA = Normal value 0-4ng/ml
o If elevated pt is advised to undergo prostate
biopsy

GENERAL GUIDELINES:
• If PSA value is between 4-10ng/ml CLINICAL PRESENTATION
= 20% chance Cap  Lesion itself
• If PSA value is ˃10ng/ml o Induration, erythema, ulceration, nodule or
= 50% chance Cap exophytic growth
• If PSA is abnormal and DRE is normal SIGNS:
- do TRUS plus biopsy  Enlarged inguinal nodes
• If PSA is normal and DRE is abnormal
- do TRUS guided biopsy plus biopsy of the

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TREATMENT:  Retroperitoneum - most common site
1. PRIMARY LESION
 Biopsy Lymphatic spread(NTK)
 Carcinoma in situ  Right testis - inter-aorto-caval
 Complete excision with adequate margins Left testis - para-aortic area
a. CIRCUMCISION  Left to Right side - no crossover metastasis
b. PARTIAL PENECTOMY- if only in the glands
c. Total penectomy with perineal urethrostomy – CLINICAL STAGING:
entire penile shaft 1. MSKCC
 If more than 2\3rds  STAGE A - Confined to the testis
 Urethra will be put below the  STAGE B - Retro-peritoneal nodes
perineum o B1 - Nodes less than 5cm
2. REGIONAL LYMPH NODE o B2 - Nodes 5-10cm
 In pts with penile ca also present with palpable anal LN o B3 - Nodes greater than 10cm
 50% inflammatory  STAGE C - Spreads beyond retroperitoneal nodes
 considered metastatic 2. TNM Classification of the American Joint Committee:
 4-6 weeks of antibiotic treatment  T PRIMARY TUMOR:
 Lymphadenectomy – LN removal Tx: -Cannot be assessed
*2cm – adequate margin for it to not regrow later on TO: -No evidence of primary tumor
*inguinal LN- stage 3 Tis: -Intratubular cancer (Cis)
* if one gives antibiotic treatments for a month and the LN is still T1: -Limited to the testis
there it means it is already secondary metastasis- if penectomy is T2: -Invades beyond tunica albuginea or epididymis
done explore inguinal area to remove inguinal LN that is affected T3: -Invades spermatic cord
T4: -Invades scrotum
D. TUMORS OF THE TESTIS:  N REGIONAL LYMPH NODE:
NX: -Cannot be assessed
NO: -No regional lymph node metastasis
N1: -Microscopic lymph node metastasis
N2a: -Metastasis in <5 nodes, none >2cm
N2b: -Metastasis in >5 nodes or any node <2cm
N3: -Extra-nodal invasion
N4: -Unresectable retro-peritoneal metastasis
 M DISTANT METASTASIS:
Mx: Cannot be assessed
MO: No distant metastasis
M1: Distant metastasis present
-
CLINIAL FINDINGS:
 Always presents with a painless palpable mass
1. SYMPTOMS:
 20-30 y\o
 painless enlargement of the testis
TYPES:
 acute testicular pain
GERM CELL TUMORS
 back pain(10% are related to metastatic disease)
 comprises90-95% are germ cell tumors (seminoma and
nonseminoma)  asymptomatic (10%)
2. SIGNS:
 5-10% are non germ cell (leydig, sertoli,
gonadoblastoma)  Testicular mass
 more common on right side than on the left  - Hydrocele
 General Considerations:  Bulky retro-peritoneal nodes
o 90-95% - germ cell tumors  Gynecomastia
o 5-10% - non germ cell  Hemoptysis
 Relative risk of malignancy 3. TUMOR MARKERS:
Undescended tetsis  Alpha-fetoprotein (AFP)
o intra-abdominal testis (1 in 20)  Human chorionic gonadotropin (HCG)
o inguinal testis (1 in 80).  Lactic acid dehydrogenase (LDH)- tell tumor burden
o Orchiopexy does not alter the malignant  Placental alkaline phosphatase (PLAP)
potential  Gamma-glutamyl transpeptidase (GGT)
 Done for observation 4. IMAGING
o facilitates examination and tumor detection - Ultrasound of the testis
CLASSIFICATION) - Chest x-ray
1. SEMINOMA - CT scan
o Most common germ cell tumor* 5. DIFFERENTIAL DIAGNOSIS:- all benign
o CLASSICAL - 85% a. Epididymoorchitis
o ANAPLASTIC - 5-10% b. Epididymitis
o SPERMATOCYTIC - 5-10% c. Hydrocele
(non semimoma) d. Spermatocele-epididymal cysts
2. EMBRYONAL CELL CARCINOMA e. Varicocele- ligated internal spermatic vein
o ADULT TYPE f. Hematocele
o VARIANT or YOLK SAC TUMOR g. Epidermoid cyst
3. TERATOMA
o may be seen in both children and adults TREATMENT:
4. CHORIOCARCINOMA  LOW STAGE SEMINOMA:
 syncitiotrophoblast and cytotrophoblast o Radical orchiectomy + Retroperitoneal
 aggressive→ early hematogenous spread irradiation
 paradoxically→ small intra-testicular lesions  HIGH STAGE SEMINOMA:
 testis looks same as norml o Radical orchiectomy + Primary
Chemotherapy
PATTERNS OF SPREAD:  · LOW STAGE NSGCT:
 With the exception of choriocarcinoma w/c o Radical orchiectomy + RPLND
demonstrates early hematogenous spread  HIGH STAGE NSGCT:
o Radical orchiectomy + Primary platinum

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 based chemotherapy DIAGNOSIS:
chemotherapy safe for high stage patients  Imaging Studies:
- EXCRETORY UROGRAPHY
E. URETERAL TUMORS - RETROGRADE UROGRAPHY
EPIDEMIOLOGY: - ANTEGRADE PYELOGRAPHY
 Rare - COMPUTED TOMOGRAPHY
 10 cases in 100,000 per year - ULTRASONOGRAPHY
 3x more common in men; 2x in whites - MRI
 Peak incidence 75-79 y/o - CYSTOSCOPY- dx imaging of choice
 Associated with Balkan Nephropathy - CYTOPATHOLOGY
- URETEROSCOPY AND NEPHROSCOPY
ETIOLOGY and RISK FACTORS:
1. Smoking METASTATIC EVALUATION:
2. Coffee consumption  · CT scan
3. Analgesics  · Chest radiography- lung mets
4. Occupational factors  Bone scan
5. Chronic infections, irritations & calculi  Liver function test- considered if there is hepatic mets
6. Cyclophosphamide  · Creatinine clearance
7. Heredity  · Renal scan

LOCATION AND DISTRIBUTION OF TUMORS: TREATMENT:
 · Bilateral involvement (2%-5%)  · Low grade, low stage → conservative or radical
 · Distal (73%) surgery
 Mid (23%);  Intermediate → radical surgery
 Proximal (3%)  High grade, high stage → do poorly w/ either
conservative or radical surgery
PATHOLOGY:  With conservative surgery, tumor recurrences 7%-65%
 · Transitional Cell Carcinoma – 90%  Renal pelvic tumor – Nephroureterectomy
 · Squamous Cell Carcinoma – 0.7-7.0%  Upper and Mid Ureteral – Segmental resections for
 · Adenocarcinoma - <1% low grade and solitary
 · Inverted Papilloma – 18%  Nephroureterectomy – for multifocal or moderately or
NONUROTHELIAL TUMORS OF THE UPPER URINARY TRACT poorly differentiated
 · Sarcomas  Distal ureters – Distal ureterectomy and
o Leimyosarcoma ureteroneocystostomy assuming no evidence of
o Carcinosarcoma multifocality
o Leimyomas *if seen in the renal pelvis need to remove from the kidney down
o Neurofibromas to the ureter
o Small cell carcinomas · Conservative surgery are especially appropriate for solitary or
o Plasmacytomas functionally dominant kidneys; bilateral tumors; small polypoid,
 Angiosarcomas low grade ureteral tumors
 Fibroepithelial polyps
*· Surgical excision is the prepared treatment F. RENAL PARENCHYMAL NEOPLASM
BENIGN TUMORS:
NATURAL HISTORY: 1. RENAL ADENOMA (NTK)
PATTERNS OF SPREAD: · Most common
 Direct invasion · Small, well-differentiated glandular tumors
 Epithelial extension · True incidence is unknown
 Lymphatic invasion · No clinical, histologic or immunohistochemical
 Vascular invasion criteria

DIAGNOSTIC INDICATORS: 2. ANGIOMYOLIPOMA (RENAL HAMARTOMA)

TUMOR STAGE AND GRADE  Rare benign tumor
 Most useful prognostic factors  Characterized by 3 major histologic components:
 Tumor stage is more accurate predictor o Mature fat cells
 Low grade tumor (median survival) = 67mos. o Smooth muscle
 High grade = 4mos. o Blood vessels
 Low stage = 97mos.  · Diagnostic: UTZ and CT in lesions w/ high fat content-
 High stage = 13mos. determine density of mass
*the higher the grade the lesser the survical Management:
 Lesions < 4 cm: observation - asymptomatic
STAGING OF LESION:  Lesions > 4 cm with moderate or severe symptoms
Tis - Carcinoma in situ  renal sparing surgery or embolization
T1 - Invade lamina propria
T2 - Invade muscularis propria 3. OTHER RARE BENIGN RENAL TUMORS
T3 - Peripelvic/periureteral tissue a). Leimyomas
T4 - Contigous organs b). Hemangiomas
N1 - Only one node</=to 2cm. c). Lipomas
N2 - One positive node >2cm., <5cm. d). Juxtaglomerular cell tumors
N3 - >5cm. In diameter
M1 - Hemogenous or distant nodal spread RENAL CELL CARCINOMA (RCC)
 3% of adult cancers and constitutes approximately
SIGNS AND SYMPTOMS: 85% of all primary malignant renal tumors
th th
 Gross or microscopic hematuria
 Occurs in the 5 -6 decade and has a male-to-female
 Flank pain- eg blood clot that impinges the ureter
ratio of 2:1
 · Acute colic
 Other terms used to described RCC:
 10%-15% → asymptomatic - Hypernephroma
- Clear carcinoma- good prognosis
- Alveolar carcinoma

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ETIOLOGY: d. Renal angiography
 Unknown e. Radionuclide imaging
 Environment and occupational exposures f. MRI
 Cigarette smoking 5. FINE NEEDLE ASPIRATION
 Exposure to asbestos and tanning products 6. INSTRUMENTAL AND CYTOLOGIC
 Inherited EXAMINATION
 Acquired 7. TUMOR MARKERS
 Sporadic DIFFERENTIAL DIAGNOSIS:
PATHOGENESIS: 1. Simple Cyst
· Histologic type: 2. Benign renal masses
a. Clear cell – 25% 3. Renal abscess
b. Granular – 25% 4. Renal lymphoma
c. Mixed 5. TCC of the renal pelvis
d. Sarcomatoid – 2% 6. Adrenal CA
 RCCs are vascular tumors that tend to spread by direct 7. Metastatic disease
extension TREATMENT
 1/3 of patients have evidence of metastasis at 1. Localized disease:
presentation · Surgical removal
· Preoperative renal artery involvement
 Good pro
2. Disseminated disease:
 Most common site of metastasis is the lung
· Surgery
· Radiation Therapy
STAGING:
· Hormonal Therapy
· The goal to select therapy and prognostication
· Chemotherapy
STAGE I -Tumor is confined within the kidney
· Radioimmunotherapy
STAGE II -Tumor involves the perinephric fat but
· Biologic Response Modifiers
is confined w/in gerotas fascia
- Interferon-alpha
STAGE IIIA –Tumor involves the main vein or
- Interleukin-2 (IL-2)
inferior vena cava
DISORDERS OF THE KIDNEYS
STAGE IIIB –Tumor involves regional lymph nodes
CONGENITAL ANOMALIES OF THE KIDNEY
STAGE IIIC –Tumor involves both local vessels and
Occur more frequently in the kidney than in any other organ
regional lymph nodes
Some may not cause any dysfunction
STAGE IVA -Tumors involves adjacent organs other
Other congenital anomalies (hypoplasia, polycystic kidneys) cause
than adrenal (colon, pancreas, etc.)
impairment of renal function.
STAGE IVB -Distant metastasis
I. AGENESIS
A. BILATERAL RENAL AGENESIS:
CLINICAL FINDINGS:
 of all anomalies of upper urinary tract, it has the most
1. SYMPTOMS AND SIGNS
profound effect on individualINCIDENCE:
 RCC is associated with a variety of presenting signs
 rare, no more than 400 cases
and symptoms (internists tumor)
 male predominance
 The classic triad of
o gross hematuria,  monozygotic twins
o flank pain,
o palpable mass occurs in only 10-15% and is EMBRYOLOGY:
frequently a manifestation of advanced  The absence of a nephrogenic ridge on the dorso-
disease lateral aspect of coelomic cavity or the failure of a
 60% presents w/ gross or microscopic hematuria ureteral bud to develop from the wolffian duct will lead
- Pain, an abdominal mass, or both, are seen in 40% to agenesis of the kidney.
- Symptoms secondary to metastatic disease lead to a
DESCRIPTION:
diagnosis in up to 30%
Kidneys are generally completely absent on gross inspection
PARANEOPLASTIC SYNDROMES ▪ Occasionally: small mass of mesenchymal tissue
a. Erythrocytosis – secondary to increase erythro poorly organized and containing primitive glomerular elements
poeitein ▪ No identifiable renal artery present
b. Hypercalcemia ▪ Ureter wholly or partially absent
ASSOCIATED ANOMALIES:
c. Hypertension
d. Stauffer Syndrome ▪ Low birth weight (1000-2500 gins.)
(58 min) ▪ At birth oligo-hydramnios
e. Other biologically active products that result in clinically ▪ In addition characteristic appearance of
significant syndrome: the face and extremities
1. ACTH - Cushing Syndrome ▪ Infants: look prematurely senile,
2. Enteroglucagon - Protein enteropathy prominent fold of skin that begins on the
3. Prolactin - Galactorrhea eye, swings down in a semi-circle over
4. Insulin - Hypoglycemia the inner canthus and extends onto the
5. Gonadotropins - Gynecomastia cheek
▪ Nose blunted, ears low sets, legs bowed &
clubbed, skin is dry secondary to dehydration &
decreased libido
lose of subcutaneous fats
hirsutism ▪ Pulmonary hypoplasia
male pattern balding ▪ Bell shaped chest
amenorrhea DIAGNOSIS:
▪ Characteristic potter facies and oligohydramnios are
pathognomonic
3. LABORATORY FINDINGS:
a. Anemia – Occurs in 30% of patients ▪ Amnion nodosum
b. Gross or microscopic hematuria ▪ Anuria after first 24 hours of life w/out
c. Elevated sedimentation rate bladder distention
4. RADIOLOGICAL PROCEDURES: CONFIRMATORY DIAGNOSIS:
a. IVP ▪ Excretory Urography
b. Ultrasound ▪ Renal UTZ
c. CT scan ▪ Renal Scan
▪ Umbilical Artery Catheterization

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PROGNOSIS: 5. ANGIOGRAPHY
▪ Infants do not survive on the first 24 X-ray Finding: Both renal shadows are usually enlarged
hours because of the RDS on plain film of abdomen 5x normal size, >16cm.
UNILATERAL RENAL AGENESIS
Differential Diagnosis:
▪ Complete absence of one kidney, occurs more 1. Bilateral Hydronephrosis
frequently 2. Bilateral Renal Tumor
▪ Diagnosis: usually not suspected and remains 3. Von Hippel-Lindau Disease
undetected 4. Tuberous Sclerosis
▪ Usually on the left side 5. Simple cyst
DIAGNOSIS: Treatment:
▪ Generally, there are no specific symptoms heralding A. General Measures
an absent kidney ▪ Low protein diet (0.5-0.75)
▪ Renal UTZ, cystoscopy ▪ No strenuous physical activity
PROGNOSIS: ▪ Control hypertension
▪ Increase pyelitis ▪ Hemodialysis
▪ Nephro & Ureterolithiasis B. Surgery
HYPOPLASTIC KIDNEY C. Treatment of Complication
▪ Small kidney PROGNOSIS:
▪ Fetal alcohol syndrome ▪ Children have poor prognosis
▪ Renal anomalies have been reported in ▪ 35-40 y/o --- favorable
infants SIMPLE (SOLITARY) CYST:
with utero cocaine exposure ▪ Congenital or acquired
▪ Accompanied by small renal arteries and branches ▪ Grows → compression → destroy renal parenchymal → rarely
(HPN) destroy so much tissue
SUPERNUMERARY KIDNEY ▪ Compress ureter → progressive
▪ is truly an accessory organ w/ its own hydronephrosis
collecting system, blood supply & distinct ▪ Infection
encapsulated tissue Pathology:
INCIDENCE: ▪ Single, unilateral
▪ rare, male to female ratio ▪ Involving lower pole of the kidney
▪ predilection to 4-side ▪ + Symptom: 10cm in diameter
▪ 66 cases ▪ Cyst are clear amber fluid, walls are thin, blue doomed
appearance
IV. POLYCYSTIC DISEASE ▪ + Calcification of sac
hereditary disorder ▪ Superficial
diffuse involvement of both kidneys ▪ Cyst do not communicate w/ renal pelvis
no evidence of renal parenchymal maldevelopment ▪ Microscopically: Heavy fibrosis &
INFANTILE POLYCYSTIC DISEASE (IPCD): hyalinization, calcification
Autosomal recessive Clinical Findings:
Lead to death, survival is short ▪ Flank pain or back intermittent dull pain
Chronic hemodialysis prolongs survival ▪ Gastrointestinal symptoms
cause unknown except hereditary ▪ Mass in the abdomen
ADULT POLYCYSTIC DISEASE (IPCD) ▪ If infected: pain in the flank, malaise & fever
▪ most common ▪ (+) Tenderness
rd
Laboratory:
▪ it ranks 3 among causes of ESRD ▪ Urinalysis --- normal
▪ characterized by genetic transmission, diffuse ▪ Microscopic hematuria +/- → rare
bilateral progressive cystic deformity of both ▪ Renal function test is normal
kidneys & hypertension ▪ Extensive destruction of kidneys→ compensatory hypertrophy of
other kidney → normal function
▪ (+) hematuria, nephrocalcinosis, progressive renal failure, acute Diagnosis:
flank, groin pain ▪ PLAIN FILM ABDOMEN
▪ an autosomal dominant hereditary condition ▪ EXCRETORY UROGRAM
▪ almost always bilateral ▪ CT SCAN
▪ symptoms do not appear until after age 40 ▪ RENAL ULTRASONOGRAPHY
▪ kidneys are larger than normal & are studded w/cysts of various ▪ ISOTOPE SCANNING
sizes ▪ PERCUTANEOUS CYST ASPIRATION W/ CYSTOGRAPHY
Etiology and Pathogenesis: Differential Diagnosis:
▪ cysts occur because of defects in the 1. Carcinoma of the kidney
development of the collecting & urineferous 2. PCKD
tubules and in the mechanism of their joining 3. Renal Carbuncle
▪ blind secretory tubules that are connected to 4. Hydronephrosis
functioning glomeruli become cystic 5. Extrarenal Tumor
CYSTS ENLARGE → COMPRESS ADJACENT PARENCHYMA → 6. Echinococcal Cyst of Kidney
ISCHEMIA → PROGRESSIVE FRACTURE IMPAIRMENT Treatment:
Laboratory: A. Specific Measures
1. Urography
▪ Anemia 2. Dx: - leave the cyst
▪ Proteinuria 3. Surgical exploration diagnosis is doubtful
▪ Hematuria B. Treatment of Complications
▪ Pyuria ▪ Infected: Extensive anti-microbial therapy
▪ Bacteriuria ▪ Surgical excision of the extra-renal portion of the
▪ Renal clearance test is with renal cyst wall
impairment & drainage hydronephrosis
Diagnostics: ▪ (+) excision of the obstructing cyst wall relieve the
1. IVP ureteral
2. CT SCAN obstruction
3. UTZ PROGNOSIS: Good once diagnosed
4. RETROGRADE PYELOGRAPHY

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RENAL FUSION period of 1-5 days
▪ 1:1000 individual – renal fusion ▪ Painful small penile ulcers which gradually enlarge
▪ Horseshoe kidney ▪ Gram stain shows the H. Ducreyi organism
▪ Fused renal mass- contains: ▪ Ducreyi test-skin test is positive
2 excretory system COMPLICATION:
2 ureters ▪ Phimosis
ETIOLOGY & PATHOGENESIS: ▪ Paraphimosis
▪ Fusion of the 2 metanephoric occurs early in embryologic life, TREATMENT: Tetracycline 500mg, alternatively, erythromycin or
kidneys lie low in the pelvis trimethroprim
▪ They seldom ascend to the high position Lymphogranuloma venerum
Pathology: ▪ Chlamydia trachomatis
▪ Renal mass fuse early → normal rotation cannot occur → ureter ▪ Penile lesion develops after 5-21 days after sexual exposure;
must ride over the isthmus of a horseshoe kidney or transverse lesion may be papular or vesicular
the anterior surface of the fused kidney ▪ Painful enlargement of inguinal nodes, a few days or weeks later
▪ Increase hydronephrosis
▪ Vesico-ureteral reflux COMPLICATION:
▪ Horseshoe kidney isthmus joins the lower poles of each kidney ▪ Multiple sinuses from involved lymph nodes
▪ Renal mass lies lower than normal ▪Elephantiasis of the genitalia
▪ Axis-vertical, normal – oblique TREATMENT:
▪ 2 nephric masses are fused into one mass ▪ Tetracycline, erythromycin are effective
containing 2 pelvis & 2 ureters ▪ Sulfamides – for secondary infection
P.E.:
▪ Normal unless it is abnormally placed Granuloma Inguinale
▪ Horseshoe kidney possible to palpate a mass over the lower ▪ Chronic infection of the skin & subcutaneous tissue of the
lumbar spine genitalia, perineum or inguinal area w/ incubation period of 2-3
Laboratory Findings: months
▪ Urinalysis → normal ▪ Calymmato bacterium granulomatis (infection agent)
▪ Renal function → normal ▪ S/S elevation on the skin of genitals, perineum & groin; base of
▪ X-ray: Horseshoe kidney ulcer covered by pink granulation tissue
▪ Axis of 2 kidney are parallel to spine ▪ Purulent discharge of secondary infection occurs
PLAIN FILM: Large soft renal mass in one flank yet not show a LABORATORY FINDINGS:
renal shadow on the other side ▪ Donovan bodies in large monocytes
EXCRETORY UROGRAM: ▪ Weight & giemsa staining techniques
1. Horseshoe kidney COMPLICATION:
2. Crossed Renal Ectopy w/ fusion shows 2 pelvis & 2 ureters ▪ Secondary infection due to deep ulceration and tissue
3. Cake/Lump Kidney destruction
RETROGRAM UROGRAMS: Show position of the pelvis and ▪ Marked phimosis
demonstrate changes compatible w/ infection or obstruction ▪ Rectal strictures
RENAL SCANNING: Delineate the renal mass & its contour TREATMENT: Tetracycline and Amplicillin
Complication: Anogenital Herpes
▪ Ureteral obstruction ▪ Due to recurrent herpes virus type 2
▪ Hydronephrosis, stone, infection ▪ Grouped vesiculopustular lesion, secondary adenopathy in the
▪ Dystocia – large fused kidney groin
ECTOPIC KIDNEY ▪ May be associated w/ cervical carcinoma
▪ Congenital ectopic kidney, causes no symptom unless: ureteral ▪ Acyclovir ointment (5%)
obstruction and infection Prostatitis
1. SIMPLE ECTOPY ▪ Inflammation and/or infection of the prostate gland, including
▪ Simple Congenital Ectopy terminal dysuria, dysfunctional voiding, perineal pain, incresed
▪ Excretory Urogram frequency of urination and pain with ejaculation
2. CROSSED ECTOPY W/OUT FUSION CLASSIFICATION:
▪ Kidney lies on the opposite side of the body but ▪ Bacterial
it is not attached to its normal place ▪ Nonbacterial
▪ Sonography, angiography, CT-Scan ACUTE BACTERIAL PROSTATITIS
ABNORMAL ROTATION ▪ Febrile illness of sudden onset: with severe irritative symptoms,
MEDULLARY SPONGE KIDNEY positive urine cultures with boggy enlarged and tender prostate
( Cystic Dilatation of renal collecting tubules) CHRONIC BACTERIAL PROSTATITIS
▪ Congenital autosomal recessive defect ▪ Persistent bacterial infection with inflammatory cell in prostate
▪ Bilateral secretions
▪ Cystic dilatation of the tubule ▪ Long history of irritative symptoms with mild obstructive voiding
▪ Urinary stasis in tubule – infection & calculi Common Pathogen in Prostatitis:
▪ Related to PCKD ▪ Escherichia coli
▪ Symptoms: Infection, Stone formation ▪ Enterobacter
Diagnosis: ▪ Proteus
▪ Excretory Urograms: pelvis & calices are normal, (±) dilated ▪ Klebsciella
tubules ( round masses of radio-opaque material) ▪ Pseudomonas
THANK YOU! PROSTATITIS SECRETIONS → presence of bacteria
SEXUALLY TRANSMITTED DISEASES Treatment:
Syphilis ▪ Trimethoprim – sulfamethaxazole
▪ caused by spirochete treponema pallidum ▪ Ciprofloxacin
▪ occur 2-4 weeks after sexual exposure Interstitial Cystitis
▪ painless, papule or pustule (chancre) on glans, corona, foreskin, ▪ Non infection inflammation of the bladder
shaft, or pubic area and scrotum ▪ Irritative voiding symptoms secondary to decreased bladder
▪ ulcer formed, has indurated edges and clean base capacity and pain secondary to bladder filling
▪ Darkfield examination: pathogenic spirochetes in the discharge ETIOLOGY:
▪ Serologic test may remain 1-3 weeks or after the appearance of ▪ Infection
the chancre. ▪ Lymphatic congestion
TREATMENT: penicillin, tetracycline ▪ Neuropathy
Syphilis ▪ Deficient protective bladder lining
Chancroid ▪ Psychologic abnormalities
▪ Haemophilus ducreyi (gram negative streptobacillus) incubation ▪ Immunologic abnormalities

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Sexually Transmitted Disease implacated in Acute Urethritis
▪ Gonococcal urethritis
▪ Nongonococcal uerthritis
Gram Stain – distinguish between nongonococcal and gonococcal
urethritis
TREATMENT:
▪ Tetracycline or doxycycline
▪ Ciprofloxacin
COMPLICATION: Strictures, infertility

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