UROLOGY

Schwartz’s Principles of Surgery 11th Ed.

dr. WIKO WICAKSONO

IIlmu Bedah dan Ilmu Orthopedi dan Traumatologi Juli 2021

 Anatomy
Kidney and Adrenal Gland
• The kidneys are paired retroperitoneal
organs that are invested in a fibro-fatty
layer of tissue known as Gerota’s fascia
• Borders:
 Right Kidney  anterolaterally by the liver
and the ascending colon
 Left Kidney  anterolaterally by the spleen
and descending colon
 Posterolaterally by the quadratus lumborum
muscle
 Posteromedially by the psoas muscle
• The renal arteries extend from the aorta and then
branch into several segmental arteries and
arterioles before becoming glomeruli
• Each artery runs posterior to their respective renal
vein
• Each renal vein drains directly into the IVC
• The collecting system begins as minor calyces near
the renal papillae and then coalesces into major
calyces->down to the ureteropelvic junction (UPJ),-
>renal Pelvis-> Ureter
• The adrenal gland is superomedial to its respective
kidney within Gerota’s fascia
 Ureter

The ureters are smooth muscle–based tubular structures that connect

the renal pelvis to the bladder
The proximal blood supply inserts on the medial aspect of the ureter
and arises from the aorta and renal artery, and the distal blood supply
inserts laterally and arises from the surrounding iliac vessels and their
branches
The ureters initially course along the psoas muscle and then run
distally along the pelvic sidewall
The ureters enter the bladder laterally and pass through the bladder
wall at an oblique angle
The ureters propel urine into the bladder via the ureteral orifices
 Bladder and Prostate
The bladder is located extraperitoneally in the pelvis and posterior
to the pubis
The average adult bladder holds approximately 500 mL of urine;
however, in rare cases, capacity can reach up to or greater than 1000
mL
The prostate is a walnut-shaped gland that encircles the urethra and
is located in males immediately beneath the bladder neck
Smooth muscle fibers distribute throughout the gland, which can
contract and facilitate bladder outlet obstruction
The average prostate measures approximately 30 mL in volume
Vasculature to the bladder and prostate arises from the superior and
inferior vesical arteries, which branch from the internal iliac arteries
Penis
The penis is comprised of three bodies: two corpora
cavernosa, which are responsible for erection, and
the corpus spongiosum, which surrounds the urethra
and gives rise to the glans penis
These three structures are all encased by skin and
dartos fascia, as well as an inner investing layer of
fascia called Buck’s fascia
The corpora cavernosa are spongy sinusoidal bodies
that expand with parasympathetic neural stimulation
to create an erection
The corpus spongiosum is located on the ventrum of
the penis
Scrotum and Testes
The scrotum is comprised of many layers aside from skin and dartos
fascia, and each derives from a particular layer of the anterior
abdominal wall
The testes are separated from the scrotal layers by the visceral and
parietal layers of the tunica vaginalis, between which hydroceles
form
The spermatic cord contains the vas deferens, the venous
pampiniform plexus, and arterial blood supply to the superior pole
of the testis via three separate sources
The testicular artery arises directly from the aorta; the deferential
artery, which supplies the vas deferens, arises from the internal iliac
artery; and the cremasteric artery, which supplies the cremaster
musculature, arises from the external iliac artery
2. Infection
Uncomplicated Cystitis
Uncomplicated cystitis usually presents as new onset urinary, frequency, urgency, dysuria, lower
back pain, suprapubic pain, foul-smelling urine, or gross hematuria
Urinalysis with microscopy assists with diagnosis by confirming the presence of pyuria,
hematuria, and bacteriuria
Three days of antibiotics are generally sufficient for treatment of uncomplicated cystitis
Complicated Cystitis
Complicated cystitis may arise in the setting of structural or functional urinary tract
abnormalities, recent urinary tract instrumentation, recent antimicrobial use,
immunosuppressed states, pregnancy, or hospital-acquired infection
Symptoms may be similar to uncomplicated cystitis but can progress to pyelonephritis if left
untreated
Treatment consists of 10 to 14 days of antibiotics
Pyelonephritis Pyelonephritis arises when a bladder infection ascends proximally along the
ureters to the renal parenchyma, hematogenous spread, such as in the case of
intravenous drug abuse or in patients with bacteremia from other sources

present with fevers, flank pain, nausea, vomiting, and lower urinary tract
symptoms, tenderness of the costovertebral angle

Acute pyelonephritis requires 7 to 14 days of antibiotic therapy

Prostatitis
• Acute prostatitis is marked by fever, suprapubic or perineal pain, and new onset
lower urinary tract symptoms, namely dysuria, frequency, urgency, changes in stream
caliber, or difficulty emptying the bladder
• Digital rectal exam may reveal a tender and soft prostate
• Treatment consists of a long-term course (4–6 weeks) of antibiotics
• If not treated in a timely fashion, acute prostatitis can develop into severe sepsis or a
prostatic abscess
• Prostatic abscesses may require drainage via a transurethral approach or transrectal
needle aspiration
Epipidymo-Orchitis
Common etiologies include sexually transmitted infection, urinary tract infection, underlying
congenital urologic abnormality or incomplete bladder emptying
Symptoms include pain and swelling of the epididymis and testis
Physical exam generally reveals a tender, swollen epididymis and testis
Treatment of epididymo-orchitis consists of single dose of ceftriaxone and azithromycin if there
is concern for sexually transmitted infection, as well as 14 days of oral antibiotic therapy,
NSAIDs, and scrotal support
Balanitis and Balanophostitis
Balanitis refers to inflammation of the glans penis. Balanoposthitis arises when the foreskin is
also involved
Common etiologies include fungal infection, bacterial infection, contact dermatitis, or local
trauma
Exam reveals a diffusely erythematous and warm glans penis, with inner preputial erythema as
well if balanoposthitis is present
Treatment includes appropriate hygiene, topical antibiotics or antifungals, and occasionally
topical steroids
3. Urinary Tract Obstruction
Urolithiasis
• Stones are most commonly composed of calcium oxalate, calcium phosphate, uric acid, cystine,
medication-related, and infectious stones (struvite or carbonate apatite) or a mix thereof
• Evaluation for first-time stone formers should include a complete medical history and physical
exam, basic metabolic panel, calcium, uric acid, urinalysis and culture, and radiographic imaging
• Smaller and more distal stones are much more likely to pass spontaneously without the need for
surgical intervention(Ablocker)
• Patients who have not passed their stone after a 4- to 6-week observation period, those with
larger stones, or those who desire immediate intervention, may be offered one of three
definitive surgical interventions: shockwave lithotripsy (SWL), ureteroscopy (URS), or
percutaneous nephrolithotomy (PCNL)
• General preventative measures include correcting dietary habits, particularly increasing fluid
intake to produce >2.5 liters of urine per day, limiting sodium, reducing animal protein intake,
and monitoring foods high in oxalate
 Benign Prostatic Hyperplasia
• Histological findings of smooth muscle and fibroblast/epithelial cell
proliferation
• in the transition zone of the prostate
• Lower urinary tract symptoms (LUTS) may be secondary to benign prostatic
enlargement (BPE) causing progressive bladder outlet obstruction
• The first line of treatment is most commonly pharmacotherapy
• Transurethral resection of the prostate (TURP) remains the mainstay of
endoscopic procedures, with low treatment failure and complication rates
 A urethral stricture is an area of scarring or fibrosis that causes
Urethral concentric narrowing of the urethra, impeding the flow of urine
Stricture as it drains from the bladder
A stricture can occur in any segment of the urethra, but it is most
common in the bulbar urethra

Options to treat urethral stricture disease can be divided into two

general categories: endoscopic (direct vision internal
urethrotomy) and surgical reconstruction (urethroplasty)
 Other
•Retroperitoneal fibrosis (RPF) is a rare cause of ureteric obstruction secondary to an inflammatory and
fibrotic process of the retroperitoneal structures-> Idiopatic(70%). Identifiable causes periaortic
inflammation due to aneurysms, medications
•Symptoms are nonspecific and may include general abdominal discomfort or back pain, flank pain due
to ureteral obstruction, or lower extremity edema due to vena caval compression.
•Laboratory abnormalities such as normocytic anemia, an elevated C-reactive protein,
•Patients with symptomatic renal obstruction, renal insufficiency, or signs of infection should be
decompressed with either ureteral stents or nephrostomy and monitored for postobstructive diuresis.
Biopsy of the retroperitoneal mass to exclude malignancy should be considered prior to commencing
treatment. Steroid therapy remains the mainstay of medical treatment, although other
immunosuppressive agents have been described.
• If medical treatment fails, open or minimally invasive bilateral ureterolysis with intraperitonealization
or omental wrapping of the ureters is indicated.
4. Genitourinary Trauma
Kidney
The prime goal of renal trauma management is preservation of renal function. Renal
trauma has become largely nonoperative in modern times, especially in the setting of
low- to intermediate grade renal injuries from a blunt mechanism of action.
The first goal of renal trauma is to accurately grade the renal injury. The gold standard
test to diagnose and stage a renal injury includes a CT scan with IV contrast.
Criteria that would mandate renal imaging include the presence of gross hematuria,
microscopic hematuria with hypotension, and mechanisms increasing the prevalence of
renal injury (sudden deceleration injuries, flank contusion.
The American Association for the Surgery of Trauma (AAST) renal
trauma grading system
The management of renal injuries depends not only on the grade but also on the injury
mechanism and clinical symptoms.
Absolute indications for surgical or radiological intervention on renal trauma  life-threatening
hemorrhage, renal pedicle avulsion, or pulsatile/expanding retroperitoneal hematoma. suffering
penetrating renal trauma with a retroperitoneal hematoma should undergo exploration when
hemodynamic instability.
Hemodynamically stable patient with a renal Injury renal trauma should be initially observed.
Conservative management : entails bed rest and hemodynamic monitoring. Patients with a
grade 4 renal injury should be treated in the same manner, and a repeat CT scan should be done
to make certain that the urinary extravasation has resolved.
Ureters
•There is no association between the magnitude of ureteral injuryand the degree of hematuria
that is present. Unlike renal injury, the ureters more commonly are injured through iatrogenic
mechanisms
•Diagnosis requires either a CT urogram, IVP, or a cystoscopy with a retrograde pyelogram.
•The repair of ureteric injuries depends on the time of identification from initial injury, location,
and length of the injured ureteral segment involved
•Iatrogenic ureteral injuries should be initially managed with ureteral stent placement when
possible, if not possible -> open repair
•Ureteral injuries of traumatic origin (penetrating injuries, multiple intra-abdominal traumas)
should be repaired when possible. if not possible -> the ureter can be ligated with subsequent
nephrostomytube
Blader
The bladder can be injured through iatrogenic and classic traumatic mechanisms.
Indications for bladder imaging include gross hematuria in the setting of injuries with a
correlation for bladder injury.
Diagnosis of bladder injuries requires either a CT cystogram or a fluoroscopic cystogram.
5. Emergencies
6. Urologic Malignancies
7. Common Urologic Conditions
8. Pediatric Urology