1. A healthy 3-year-old girl develops a urinary tract infection (UTI). How should she be evaluated?

Show answer
After treatment of the infection, the patient should undergo a urinary tract evaluation (this recommendation stands even in a little girl after only one UTI). Evaluation includes a renal-bladder sonogram and voiding cystourethrogram (VCUG). Approximately 50% of children younger than age 12 years who present with a UTI are found to have abnormalities of the genitourinary tract. The most common abnormalities identified are vesicoureteral reflux, obstructive uropathies, and neurogenic bladder.

2. What is vesicoureteral reflux (VUR) disease?

Show answer
With VUR, urine refluxes from the bladder into the upper urinary tract. Primary VUR is caused by an inadequate valvular mechanism at the ureterovesical junction, presumably related to a shortened submucosal ureteral tunnel. One half of children with culture-documented UTIs have VUR.

3. Is VUR bad?

Show answer
Sterile reflux is unlikely to cause renal damage; however, persistent reflux of infected urine leads to pyelonephritis and progressive renal scarring. Currently, renal scarring is the fourth leading cause for renal transplantation in children. The combination of VUR and elevated bladder storage pressures (e.g., neuropathic bladder or bladder outlet obstruction) is particularly harmful to the kidney.

4. What are the indications for surgical correction of VUR?

Show answer
Reflux disappears spontaneously in many children; however, high-grade reflux, especially when bilateral, is unlikely to resolve spontaneously. Children with high-grade reflux or breakthrough UTIs despite antibiotic prophylaxis should be managed surgically. Surgical management is also appropriate in children with reflux persisting into late childhood or adolescence.

5. What is the most common cause of antenatal hydronephrosis?

Show answer
Ureteropelvic junction (UPJ) obstruction. Hydronephrosis is the most common abnormality detected on prenatal ultrasound and accounts for 50% of all prenatally detected lesions. Fifty percent of prenatal hydronephrosis, in turn, is caused by UPJ obstruction. UPJ obstruction is bilateral in approximately 20% of cases and is associated with VUR in 15% of cases.

6. What is the most common cause of UPJ obstruction?

Show answer
Intrinsic stenosis. Less common causes include lower pole (of the kidney) crossing vessels, anomalous ureteral insertions, and peripelvic fibrosis.

7. Can UPJ obstruction resolve spontaneously? What are the indications for pyeloplasty?

Show answer
Yes, it can resolve spontaneously. Ultimately, only about 25% of children with evidence of UPJ obstruction require pyeloplasty. The indications for surgical intervention include worsening hydronephrosis, poor or declining renal function, pain, and the presence of a solitary kidney or bilateral hydronephrosis.

8. What is the Meyer-Weigert law?

Show answer
This law refers to the position of the ureteral orifices in patients with complete ureteral duplication. Occasionally, two ureteral buds develop independently from the mesonephric duct. As the ureteral buds are absorbed into the developing bladder, the bud located in a lower position along the duct (draining the lower pole of the kidney) is carried to a more cranial and lateral position. The ureteral bud located in a higher position along the duct (draining the upper pole of the kidney) is carried to a more caudal and medial position within the bladder. Lower pole ureters are more likely to reflux because of their lateral position within the bladder; however, upper pole ureters are more frequently obstructed and are more often associated with a ureterocele.

9. What is a ureterocele?

Show answer
A ureterocele is a cystic dilatation of the distal portion of the ureter. Ureteroceles are usually associated with the upper pole ureter of a duplicated collecting system; however, they also may develop from single ureters. They are usually ectopic (i.e., some portion of the ureterocele is positioned at the bladder neck or urethra) and frequently cause ureteral obstruction.

10. What is an ectopic ureter?

Show answer
A ureter with an ectopic opening at the level of the bladder neck or more caudally.
KEY POINTS: PEDIATRIC UROLOGY

1. The most common cause of antenatal hydronephrosis is ureteropelvic junction obstruction.
2. A ureterocele is a cystic dilatation of the distal portion of the ureter.
3. The most common location of an undescended testicle is the inguinal canal.
4. The most common cause of ambiguous genitalia in newborns is congenital adrenal hyperplasia, most commonly due to 21-hydroxylase deficiency.

11. What is the most common presenting symptom in a girl with an ectopic ureter?

Show answer
Incontinence. In females, an ectopic ureter will usually drain into the bladder neck, proximal urethra, or vestibule. The orifice also may be located in the vagina (25%) and, occasionally, the uterus. When the ectopic ureteral orifice is positioned below the external sphincter or within the female genital tract, incontinence can develop.

12. Do boys with ectopic ureters present with incontinence?

Show answer
No. The ectopic pathway in boys extends from the bladder neck through the posterior urethra to the mesonephric duct derivatives (i.e., vas deferens, epididymis, and seminal vesicle). Therefore, the ectopic ureteral orifice is always positioned above the continence mechanism.

13. What percentage of full-term male infants have an undescended testicle?

Show answer
Three percent. This number decreases to 0.8% by age 1 year.

14. What is the most common location of an undescended testicle?

Show answer
The inguinal canal (72% of undescended testicles). The testicle also may be located in the abdomen (8%) or prescrotal area (20%). Twenty percent of undescended testicles are nonpalpable at presentation; of these, 50% are absent completely.

15. Why should the testicle be brought back into the scrotum?

Show answer
Patients with cryptorchidism have a 40-fold increased risk of germ cell cancer compared with the normal population. Although positioning of the testicle within the scrotum does not alleviate this risk, it does permit routine, thorough testicular examination. Patients with cryptorchidism also are at risk for infertility. Histologic studies have demonstrated progressive germ cell loss in the undescended testicle beginning at age 18 months. Early orchiopexy can minimize the extent of germ cell loss and thereby decrease the chance of future infertility. In general, the higher the testicle (i.e., within the abdomen), the greater the risk of cancer and infertility.

16. What is the most common cause of bladder outlet obstruction in boys? In girls?

Show answer
Posterior urethral valves and ureterocele, respectively.

17. What are the urinary manifestations of posterior urethral valves?

Show answer
Posterior urethral valves are congenital leaflets of tissue that extend from the verumontanum to the anterior urethra in boys. They occur at an incidence of 1 in 8000 live male births. Posterior urethral valves cause bladder outlet obstruction, which, in turn, leads to variable degrees of bladder and renal injury. Severe obstruction may result in oligohydramnios, pulmonary hypoplasia, bladder hypertrophy, vesicoureteral reflux, hydroureteronephrosis, and renal dysplasia. Fifty percent of affected children have reflux, and 33% of them progress to end-stage renal disease.

18. What is a myelomeningocele? What are its urologic consequences?

Show answer
A myelomeningocele is a hernial protrusion of the spinal cord and its meninges through a defect in the vertebral column. The resulting neurologic injury causes, among other problems, bladder dysfunction. Patients with myelomeningocele usually are incontinent because of detrusor hyperactivity, detrusor hypoactivity, poor bladder compliance, inadequate outlet resistance, detrusor-outlet dyssynergy, or a combination of these factors. More importantly, patients with hyperactive, high-pressure bladders may develop upper urinary tract deterioration. Life-long follow-up is necessary because the neurologic lesion can change with time. Treatment goals include maintenance of a low-pressure urinary reservoir, prevention of urinary tract infections, prevention of upper urinary tract deterioration, and the achievement of continence.

19. What is the most common cause of ambiguous genitalia in newborns?

Show answer
Congenital adrenal hyperplasia, most commonly caused by a 21-hydroxylase deficiency.

20. What diagnostic evaluation should be performed in any male infant presenting with hypospadias and cryptorchidism?

Show answer
The presence of cryptorchidism and hypospadias should alert the physician to the possibility of an androgenized female. A karyotype should always be obtained before urogenital reconstruction.

21. What is the most common solid renal mass in infancy? In childhood?

Show answer
In infancy, it is congential mesoblastic nephroma. This is a benign tumor of the kidney that can be managed with surgical excision alone.
In childhood, it is a Wilms’ tumor. Wilms’ tumor is associated with Beckwith-Wiedemann syndrome, isolated hemihypertrophy, and congenital aniridia. The most important prognostic factors are tumor stage and histology. Treatment is multimodal, consisting of surgery, chemotherapy, and radiation.

References
WEB SITE
http://www.transplantation-soc.org

BIBLIOGRAPHY
1. Baker LA, Silver RI, Docimo SG: Cryptorchidism. In Gearhart JP, Rink RC, Mouriquand PDE (eds): Pediatric Urology. Philadelphia, W.B. Saunders, 2001, pp 738-753.
2. Cooper CS, Snyder HM: Ureteral duplication, ectopy, and ureteroceles. In Gearhart JP, Rink RC, Mouriquand PDE (eds): Pediatric Urology. Philadelphia, W.B. Saunders, 2001, pp 430-452.
3. Dinneen MD, Duffy PG: Posterior urethral valves. Br J Urol 78:275-281, 1996. Medline Similar articles
4. Docimo SG: The results of surgical therapy for cryptorchidism: A literature review and analysis. J Urol 154:1148, 1995. Medline Similar articles
5. Elder JS, Peters CA, Arant BS Jr, et al: Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children. J Urol 157:1846-1851, 1997. Full article
6. Gill B, Kogan S: Cryptorchidism. Current concepts. Pediatr Clin North Am 44:1211-1227, 1997. Medline Similar articles
7. Gunther DF, Bukowski TP: Congenital adrenal hyperplasia: A spectrum of disorders. Contemp Urol 11:52-69, 1999.
8. Kirsch AJ, Escala J, Duckett JW, et al: Surgical management of the nonpalpable testis: The Children’s Hospital of Philadelphia experience. J Urol 159:1340-1343, 1998.
9. Pohl HG, Rushton HG: The diagnosis and management of urinary tract infection in children. AUA Update Series 17:242-247, 1998.
10. Poppas DP, Bauer SB: Urologic evaluation of the myelodysplastic child. AUA Update Series 16:282-287, 1997.
11. Reddy PR, Mandell J: Ureteropelvic junction obstruction: Prenatal diagnosis; therapeutic implications. Urol Clin North Am 25:171-195, 1998.
12. Snyder HM: Anomalies of the ureter. In Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds): Adult and Pediatric Urology, 3rd ed. St. Louis, Mosby, 1996, pp 2197-2228.
13. Strand WR: Urinary infection in children: Pathogenesis, bacterial virulence, and host resistance. In Gonzales ET, Bauer SB (eds): Pediatric Urology Practice. Baltimore, Lippincott Williams & Wilkins, 1999, pp 433-462.

1. What is urodynamics?

Show answer
Urodynamic studies assess the functional aspects of the storage and emptying ability of the lower urinary tract (LUT). The principles of urodynamic studies originated from hydrodynamics. The components of urodynamic studies are cystometrogram, leak point pressures, urethral profile pressures, pressure-flow studies, uroflowmetry, and electromyography. These studies have evolved into videourodynamics with the addition of fluoroscopy (i.e., video).

2. What is uroflowmetry?

Show answer
Uroflowmetry is the measurement of voided urine (in milliliters) per unit of time (in seconds). The important elements of the test are voided volume (which should be > 150 mL), maximum flow rate (Qmax), and the curve of the flow (which should be bell shaped). The normal Qmax is > 20 mL/sec in men and > 25 mL/sec in women.

3. What is benign prostatic hyperplasia (BPH)?

Show answer
BPH is benign enlargement of the prostate gland that may lead to bladder outlet obstructive symptoms in men. These symptoms have recently been termed lower urinary tract symptoms (LUTS).

4. What is an American Urological Association (AUA) symptom score?

Show answer
It is a self-reported questionnaire developed and popularized by the AUA for the assessment of bothersome LUTS in men. This questionnaire has seven questions with a maximum score of 35. The higher the score, the more severe and bothersome the symptoms. The AUA symptom score has become an index for both the diagnosis and evaluation of treatment outcome in patients with LUTS.

5. What are the main functions of the LUT?

Show answer
Storage and emptying of urine are the main functions. For practical purposes, all symptoms of LUT dysfunction can be categorized into the malfunction of either storing or emptying ability.

6. What are the control mechanisms for LUT function?

Show answer
The control mechanisms for LUT function are recognized as central and peripheral. The central control mechanisms consist of the cortical portion of the frontal lobe of the brain and pontine micturition center. The peripheral control mechanisms include the thoracic sympathetic and lumbar parasympathetic innervation and neuromuscular apparatus of the LUT organs.

7. What is the role of the autonomic nervous system in the function of the LUT?

Show answer
Sympathetic fibers, which originate from the T10-L2 portion of the spinal cord, innervate the bladder neck and proximal urethra. These fibers mostly control the contraction of the proximal urethra or bladder neck and relaxation of the bladder, which results in storage of urine. The parasympathetic fibers, which originate primarily from the S2-S4 portion of the spinal cord, innervate the bladder body. The parasympathetic innervation allows contraction of the bladder smooth muscle, leading to bladder emptying.

8. What is the role of the somatic nervous system in the function of the LUT?

Show answer
Voluntary control of the striated muscle of the external urinary sphincter is controlled by the somatic nervous system. Somatic fibers are conveyed to the sphincter by the pudendal nerve.

9. What is bulbocavernosal reflex?

Show answer
Bulbocavernosal reflex tests the integrity of peripheral neurologic control of the LUT. This reflex is elicited by stimulation of the glans penis in men or the clitoris in women, which causes contraction of the external anal sphincter or bulbocavernosus muscle. Alternatively, the reflex may be stimulated by pulling the balloon of a Foley catheter against the bladder neck. This reflex is present in all normal men and in approximately 70% of normal women. Absence of this reflex in a man is strongly suggestive of a sacral neurologic lesion.

10. What is the most common cause of incontinence in the geriatric population?

Show answer
The most common are transient causes, mostly external, that disrupt the fragile balance of LUT function in elderly patients and cause urinary incontinence. These causes can be recalled with the mnemonic DIAPPERS:

* Delirium
* Infections
* Atrophic urethritis or vaginitis
* Pharmaceuticals
* Psychological (depression)
* Endocrine (hypercalcemia, hyperglycemia)
* Restricted mobility
* Stool impaction

KEY POINTS: URODYNAMICS AND VOIDING FUNCTION

1. Uroflowmetry is the measurement of voided urine (in milliliters) per unit of time (in seconds).
2. Benign prostatic hypertrophy is benign enlargement of the prostate gland that may lead to bladder outlet obstructive symptoms in men.
3. The sacral roots involved in micturition physiology are S2-S4.

11. What is spinal shock? What type of urinary dysfunction does it cause?

Show answer
Spinal shock is the loss of contractility of the smooth muscle below the level of spinal cord injury, leading to difficulty in bladder emptying or urinary retention. This phenomenon may last from hours to several months with a high chance of reversibility if the spinal cord injury is not permanent.

12. What is autonomic dysreflexia? How is it treated?

Show answer
Autonomic dysreflexia results from systematic outpouring of sympathetic discharge, as in patients with spinal cord lesions at or above the T6 level. This dysreflexia is triggered by distention of the bladder or other stimulus of the bowel or LUT. It is manifested by hypertension, bradycardia, hot flush, sweating, and headache. Initial treatment consists of removal of the stimulus, such as emptying the bladder and placing the patient in a sitting position. Nifedipine or nitroprusside may be used as either prophylaxis or treatment of severe episodes. This condition may lead to significant cerebrovascular complication if untreated.

13. What type of bladder dysfunction is seen in diabetic patients?

Show answer
Diabetic cystopathy is manifested primarily as atonic bladder with difficulty in emptying caused by impaired contractility of the bladder or detrusor muscle.

14. What type of bladder dysfunction is seen in patients with multiple sclerosis (MS)?

Show answer
Urgency (83%), urge incontinence (75%), detrusor hyperreflexia (62%), and detrusor sphincter dyssynergia (25%) are among the most common LUT symptoms in patients with MS. Variation in symptoms depends on the site of involvement by MS. Involvement of pontine pathways (tegmentum) is associated with a much higher rate of urinary symptoms.

15. Which sacral roots control the micturition physiology?

Show answer
S2-S4.
16. What are the causes of urinary retention after abdominal or pelvic surgery? Show answer
They are injuries or disruption of pelvic plexus innervation to the LUT.

17. What is Ogilvie’s syndrome?

Show answer
Acute massive dilatation of the cecum and ascending and transverse colon without organic obstruction is known as Ogilvie’s syndrome. This syndrome can be seen in pelvic urologic surgeries, possibly as a result of an imbalance in parasympathetic stimulation of the colon.

18. What is reflex versus psychic erection?

Show answer
Erection after local stimulation is termed reflex erection. The afferent nerves for reflex erection run in the pudendal nerves, and the efferent fibers are found in the S2-S4 parasympathetic outflow. The psychic erection is caused by stimulation of cerebral erotic centers. The afferent stimuli for psychic erection travel through the thoracolumbar sympathetic outflow and sacral parasympathetic fibers.

References
WEB SITE
http://www.transplantation-soc.org
BIBLIOGRAPHY
1. Bross S, Braun PM, Michel MS, et al: Preoperatively evaluated bladder wall tension as a prognostic parameter for postoperative success after surgery for bladder outlet obstruction. Urol 61:562-566, 2003. Medline Similar articles Full article
2. Holtgrewe HL: Current trends in management of men with lower urinary tract symptoms and benign prostatic hyperplasia. Urology 51(suppl 4A):1-7, 1998.
3. Litwiller SE, Forhman EM, Zimmern PE: Multiple sclerosis and the urologist. J Urol 161:743-757, 1999. Medline Similar articles Full article
4. Mochrer B, Carey M, Wilson D: Laparoscopic colposuspension: A systematic review. Br J Obstet Gynaecol 110:230-235, 2003.
5. Resnick NM, Yalla SV: Geriatric incontinence and voiding dysfunction. In Walsh PC, Retik AB, Vaughan ED, et al (eds): Campbell’s Urology, 7th ed. Philadelphia, W.B. Saunders, 1998.
6. Steers WD, Barrett DM, Wein AJ: Voiding dysfunction, diagnosis, classification and management. In Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds): Adult and Pediatric Urology, 3rd ed. St. Louis, Mosby, 1996.
7. Wang CC, Yang SS, Chen YT, Hsieh JH: Videourodynamics identifies the causes of young men with lower urinary tract symptoms and low uroflow. Eur Urol 43:386-390, 2003.

11. Is there any type of stone that cannot be seen on helical CT scan?

Show answer
Patients taking indinavir sulfate (Crixivan) for HIV infection can form stones from the crystals of the medication; these stones are not seen on CT scan.

12. What toxic substance can be produced by using the holmium:YAG laser on uric acid stones?

Show answer
Cyanide is produced from the uric acid. Although this sounds frightening, it is never a problem.

References
WEB SITE
http://www.transplantation-soc.org
BIBLIOGRAPHY
1. Menon M, Resnick M: Urinary lithiasis: Etiology, diagnosis and medical management. In Walsh PC, Retik AB, Vaughan ED, Wein AJ et al (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 3229-3305.
2. Teichman JM, Vassar GJ, Glickman RD: Holmium: YAG lithotripsy photothermal mechanism converts uric acid calculi to cyanide. J Urol 160:320-324, 1998. Medline Similar articles Full article

1. How common is prostate cancer?

Show answer
It is the most common malignancy diagnosed in men in the United States; almost 200,000 new cases were diagnosed in 2001.

2. Do most men die with prostate cancer, rather than from it?

Show answer
Yes, but approximately 31,500 men died of prostate cancer in 2001 in the United States. Thus, it should not be treated as benign.

3. What are the early symptoms of prostate cancer?

Show answer
There are none. By the time significant symptoms develop, the disease is likely to be advanced. This is an argument for screening to detect prostate cancer.

4. What is the best screening method for prostate cancer?

Show answer
Digital rectal examination (DRE) combined with serum prostate-specific antigen (PSA). Since PSA testing was introduced, there has been a stage migration with less metastatic disease and more local-regional disease being detected.

5. How is prostate cancer diagnosed?

Show answer
It is diagnosed with prostate biopsy, which is a biopsy using transrectal ultrasound for guidance. Many cancers are discovered incidentally at transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH).

6. When is prostate biopsy indicated?

Show answer
When either the PSA or DRE result is abnormal.
KEY POINTS: PROSTATE CANCER

1. Prostate cancer is the most common malignancy diagnosed in men in the United States.
2. The best screening method is a combination of digital rectal exam and serum prostate-specific antigen.
3. Clinically localized prostate cancer is treated with surgery, radiation, cryotherapy, or watchful waiting.

7. Does an elevated PSA level mean a man has prostate cancer?

Show answer
No. PSA can be elevated with BPH, prostatitis, or after prostate trauma. It is prostate specific, not prostate cancer specific.

8. What is a free PSA?

Show answer

Free PSA is the percentage of PSA that is not bound to a serum protein carrier. The ratio of free to total PSA is helpful in determining when to do a prostate biopsy. “Free” is good because a higher ratio of free to total PSA is less likely to represent a prostate cancer.

9. Are there any known risk factors for prostate cancer?

Show answer
Yes. African-American men and men with a family history of prostate cancer are at an increased risk. A high-fat diet may play a role in increasing risk of many cancers, including prostate cancer.

10. What is Gleason’s sum?

Show answer
It’s a score that the pathologist gives prostate cancer to estimate its aggressiveness. The two predominant patterns of cancer are scored 1 to 5, and the sum is, therefore, between 2 and 10. Tumors can be well differentiated (2, 3, 4), moderately differentiated (5, 6, 7), or poorly differentiated (8, 9, 10).

11. How is clinically localized prostate cancer treated?

Show answer
Surgery (radical prostatectomy), radiation therapy by external beam or interstitial seed implant, cryotherapy, or watchful waiting.

12. How is advanced metastatic prostate cancer treated?

Show answer
Hormonal ablation therapy (orchiectomy or luteinizing hormone-releasing hormone agonist drugs) or chemotherapy, but these treatments are palliative and not curative.

13. What is the best treatment for prostate cancer?

Show answer
This is highly controversial. Patients must weigh factors such as age, overall health, grade and stage of the disease, and risk of side effects versus complications from the various treatment options.

References
WEB SITE
http://www.transplantation-soc.org
BIBLIOGRAPHY
1. Catalona WJ: Clinical utility of free and total prostate specific antigen. Rev Prostate 7(suppl):64-69, 1996.
2. D’Amico AV, Whittington R, Malkowicz SB, et al: Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 280:969, 1998.
3. Greenlee RT, Hill-Harmon MB, Murray T, Thun M: Cancer statistics 2001. CA Cancer J Clin 51:15-36, 2001.
4. Keetch DW, Humphrey PA, et al: Clinical and pathological features of hereditary prostate cancer. J Urol 155:1841-1842, 1996. Medline Similar articles Full article
5. Polascik TJ, Pound CR, et al: Comparison of radical prostatectomy and iodine-125 interstitial radiotherapy for the treatment of clinically localized prostate cancer: A 7-year biochemical (PSA) progression analysis. Urology 51:884-890, 1998. Full article
6. Resnick MI, Novick AC: Urology Secrets, 2nd ed. Philadelphia, Hanley & Belfus, 1999.
7. Reiter RE, deKernion JB: Epidemiology, etiology, and prevention of prostate cancer. In Walsh PC, Retik AB, Vaughan ED, et al (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 3003-3024.

13. In certain countries, TCC is not the predominant form of bladder cancer. What is the predominant histologic type? Why?

Show answer
In countries such as Egypt, where schistosomiasis is endemic, squamous cell carcinoma of the bladder is common.

14. Can any markers be used to help predict the prognosis of TCC?

Show answer
The p53 tumor suppressor protein may be helpful in assessing the biologic behavior of the tumor and can assist with treatment option decisions. Monoclonal antibody MIB-1 may also be useful in predicting outcome for stage T2 or grade 2 tumors.

References
WEB SITE
http://www.transplantation-soc.org
BIBLIOGRAPHY
1. Greenlee RT, Hill-Harmon MB, Murray T, Thun M: Cancer statistics 2001. CA Cancer J Clin 51:15-36, 2001.
2. Herr HW, Bajorn DF, Scher HL: Can p53 help select patients with invasive bladder cancer for bladder preservation? J Urol 161:20, 1999.
3. Messing EM: Urothelial tumors of the urinary tract. In Walsh PC, Retik AB, Vaughan ED, et al (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 2732-2784.
4. Resnick MI, Novick AC: Urology Secrets, 2nd ed. Philadelphia, Hanley & Belfus, 1999.

1. How common is bladder cancer?

Show answer
Approximately 54,300 new cases of bladder cancer were diagnosed in 2001 in the United States, and 12,400 patients died. The male-to-female ratio is almost 3:1.

2. What are the risk factors for bladder cancer?

Show answer
Cigarette smoking, exposure to aniline dyes or aromatic amines, phenacetin abuse, and chemotherapy (cyclophosphamide).

3. How does bladder cancer present?

Show answer
Painless hematuria (gross or microscopic). Frequency, urgency, and dysuria also may be presenting symptoms, especially for carcinoma in situ (CIS).

4. What is the most common histologic type of bladder cancer?

Show answer
Transitional cell carcinoma (TCC) makes up > 90% of bladder cancers. Other histologic types include adenocarcinoma, squamous cell carcinoma, and urachal carcinoma.

5. How is TCC of the bladder treated?

Show answer
With transurethral resection of the bladder tumor. Further treatment is determined by the pathologic stage of the disease.

6. Is CIS a less aggressive type of bladder cancer?

Show answer
No. TCC in situ is a flat but poorly differentiated tumor. It can metastasize and should be treated as an aggressive form of bladder cancer.

7. How is CIS treated?

Show answer
Immunotherapy with intravesical bacillus Calmette-Guérin (BCG) is currently the first-line treatment. Response rates to BCG approach 70%. Other intravesical agents, such as mitomycin C, are generally less effective than BCG.

8. What are the side effects of BCG?

Show answer
Mild symptoms of urinary frequency, urgency, and dysuria are common. Myalgias and low-grade fever (flulike symptoms) also occur. High or persistent fever suggests a more serious problem requiring antituberculous therapy. Rarely, death from BCG has been reported.

9. How is muscle-invasive bladder cancer treated?

Show answer
Radical cystectomy (or cystoprostatectomy in men) with some form of urinary diversion.

10. What types of urinary diversion are used with radical cystectomy?

Show answer
Diversion techniques require either a conduit or a continent reservoir. The most common is an ileal conduit. An external collection device must be worn with a conduit. Continent reservoirs are made of combinations of large and small bowel and must be emptied via the urethra or a continent stoma.

KEY POINTS: BLADDER CANCER

1. Bladder cancer presents as painless hematuria.
2. The most common histologic type is transitional cell carcinoma.
3. Carcinoma in situ of the bladder is treated with intravesical bacillus Calmette-Guérin.

11. How is metastatic bladder cancer treated?

Show answer
Metastatic bladder cancer requires chemotherapy. Most regimens include a platinum-based agent.

12. Can invasive bladder cancer be cured without removal of the entire bladder?

Show answer
This issue is controversial. Some cancers may be suitable for partial cystectomy (i.e., tumors isolated in the dome of the bladder). Investigations are ongoing to evaluate transurethral resection of bladder tumor plus radiation and chemotherapy to try to preserve the bladder in invasive TCC.

References
WEB SITE
http://www.transplantjournal.com
BIBLIOGRAPHY
1. Figlin RA: Renal cell carcinoma: Management of advanced disease. J Urol 161:391, 1999.
2. Greenlee RT, Hill-Harmon MB, Murray T, Thun M: Cancer statistics 2001. CA Cancer J Clin 51:15-36, 2001.
3. Novick AC, Campbell SC: Renal tumors. In Walsh RC, Retik AB, Vaughan ED, et al (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 2672-2731.
4. Resnick MI, Novick AC: Urology Secrets, 2nd ed. Philadelphia, Hanley & Belfus, 1999.

1. How common is renal cell carcinoma?

Show answer
In the United States, 30,000 new cases of renal cell carcinoma are predicted for 2004 and 2005, about 3% of all adult malignancies.

2. How is kidney cancer detected?

Show answer
The classic triad of hematuria, flank pain, and an abdominal mass is used; however, this triad is found in only about 10% of cases. About 20% of renal cell carcinomas are associated with a paraneoplastic syndrome. Many solid renal tumors are detected incidentally by a computed tomography (CT) scan of the abdomen performed for another reason.

3. Are all solid masses in the kidney renal cell carcinoma?

Show answer
No. Other solid masses include angiomyolipomas, oncocytomas, sarcomas, and metastatic lesions. However, all solid masses should be presumed to be renal cell carcinoma until proven otherwise.

4. What is the unique relationship between renal cell carcinoma and its vasculature?

Show answer
Renal cell carcinoma has a tendency to invade its own venous drainage. Tumor thrombus may extend along the renal vein into the inferior vana cava and even to the right atrium.

5. How should suspected involvement of the vena cava be evaluated?

Show answer
Magnetic resonance imaging or venacavography.

6. How is renal cell carcinoma treated?

Show answer
Surgery is the optimal treatment for localized renal cell carcinoma. The standard operation is a radical nephrectomy, including everything within Gerota’s fascia. Radical nephrectomy can also be performed laparoscopically or with hand-assisted laparoscopic techniques.

7. Does the whole kidney have to be removed in all cases of renal cell carcinoma?

Show answer
No. Nephron-sparing surgery can be performed in cases of bilateral renal cell carcinoma or renal cell carcinoma in a solitary kidney. Because of the risk of postoperative tumor recurrence, nephron-sparing surgery in the presence of a normal contralateral kidney is, at best, controversial.

8. How is metastatic renal cell carcinoma treated?

Show answer
Chemotherapy has been disappointing. The most encouraging results to date are with interleukin-2 (IL-2) treatment; some evidence of definite durable responses has been noted. Research is ongoing using IL-2 with other forms of immune-enhancing strategies. Some forms of adoptive immunotherapy have been encouraging.

KEY POINTS: RENAL CELL CARCINOMA

1. What are the most common types of urinary stones found in North America?

Show answer

* Calcium stones (calcium oxalate, calcium phosphate, or mixed calcium stones): 70%.
* Struvite or magnesium ammonium phosphate stones, often associated with infection: 20%.
* Uric acid stones (radiolucent): 5%
* Cystine stones, often with a genetic association: 5%

2. What are the typical presenting symptoms of a patient with an obstructing stone?

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* Pain, usually colicky in the flank or radiating to the groin; patients are usually agitated and cannot get in a comfortable position
* Hematuria, gross or microscopic
* Nausea and vomiting caused by obstruction and pressure on the renal capsule

3. What studies are best to diagnose stones?

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1. Excretory urogram, or intravenous pyelogram (IVP). Ninety percent of stones are radiopaque and can be seen on a plain radiograph of the kidney, ureter, and bladder (KUB). The IVP serves as a functional study to determine the degree of obstruction, level of obstruction, and presence of a contralateral kidney.
2. Currently, rapid-sequence helical computed tomography (CT) scan has gained popularity. Helical CT can accurately identify both renal and ureteral stones. Its advantages include no need for contrast; speed; and ability to identify calcium, uric acid, and cystine stones. Disadvantages include increased cost compared with IVP and inability to distinguish between radiolucent (uric acid) stones and radiopaque (calcium-containing) stones. A KUB should be obtained if the CT has positive results, to distinguish between radiolucent and radiopaque stones.
3. Ultrasound is particularly advantageous in pregnant women.

4. When should a patient with an obstructing stone be admitted to the hospital?

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* Any sign of infection (e.g., fever, leukocytosis, bacteriuria); infection behind an obstructing stone may result in urosepsis and death
* Intractable vomiting requiring intravenous (IV) fluids
* Pain requiring parenteral analgesics
* Bilateral obstructing stones or obstruction in a solitary kidney

5. What are the treatment options for ureteral calculi?

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* Wait and watch to see if the stone passes; it usually does. Approximately 90% of stones, 3 mm in size in the distal ureter, will pass. Fifty percent of 5-mm stones will pass, and 20% of stones larger than 6 mm will pass.
* Ureteroscopy and stone basketing or intraureteral lithotripsy (stone blasting) with a laser (holmium, pulsed dye) or electrohydraulic lithotripsy (EHL)
* Extracorporeal lithotripsy (ESWL), or shock waves directed at the stone to break it into small pieces that can then pass spontaneously
* Open ureterolithotomy, now rarely used because of the success of the less invasive techniques listed above

KEY POINTS: URINARY CALCULUS DISEASE

1. The most common stones in patients in the United States are calcium stones.
2. Excretory urogram or intravenous pyelogram, rapid-sequence helical CT, and ultrasound are the imaging studies used to diagnose stones.
3. Steinstrasse is a collection of small calculi that pile up together in the ureter and cause obstruction or symptoms.

6. What are the treatment options for renal calculi?

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* Expectant management in asymptomatic noninfectious stones
* ESWL
* Ureteropyeloscopy with lithotripsy using a laser. This has become more popular with smaller, flexible, deflectable ureteroscopes, but it is still a challenging procedure for large stones.
* Percutaneous nephrostolithotomy (particularly for stone burden > 2 cm)
* Combination of ESWL and percutaneous nephrostolithotomy
* Open lithotomy (less common because of the success of less invasive treatment options)

7. What is a steinstrasse?

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Steinstrasse (German for “stone street”) is a collection of small calculi that pile up together in the ureter and cause obstruction or symptoms. This problem may occur after lithotripsy treatment.

8. What is a stent?

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A stent is a small plastic catheter that coils in the renal pelvis, traverses the ureter, and coils in the bladder. Stents are useful to relieve ureteral obstruction temporarily and possibly facilitate stone passage after the stent is removed. Stents often cause some degree of ureteral dilatation after they have been removed.

9. What is a metabolic evaluation? Who needs one?

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A metabolic evaluation involves examining both serum and 24-hour urine specimens for factors that contribute to stone formation. The goals are to identify an abnormality and to treat it medically to prevent further stone formation. Indications for metabolic evaluation include recurrent stones, multiple stones, bilateral stones, stones in children, and non-calcium-containing stones.

10. Can stones be dissolved?

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* Uric acid stones often can be dissolved by alkalinizing the urine and with hydration therapy.
* Cystine, struvite, and apatite stones sometimes can be dissolved.
* Calcium stones cannot be dissolved.

1. How common a problem is infertility?

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Infertility is the inability to establish a pregnancy during 1 year of well-timed intercourse. This affects 15% of all couples in the United States. In 50% of such couples, the woman is responsible; in 30% of couples, a male factor prevents pregnancy; and in 20% of couples, it is a combination of both.

2. What are the odds that a fertile couple will become pregnant after a single episode of well-timed intercourse?

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During a given ovulatory cycle, 18% of fertile couples become pregnant after well-timed intercourse.

3. What is the best timing for intercourse if a couple is trying to conceive?

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Sperm can survive in the cervical mucus for 48 hours. To achieve pregnancy, therefore, the most effective timing of intercourse is every other day, starting a few days before ovulation.

4. What environmental factors may play a role in male infertility?

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Although reproductive function is relatively durable, various toxins have a negative impact on male fertility. Cigarette smoke and alcohol have been implicated as dose-dependent gonadotoxins, as have recreational drugs, including marijuana, cocaine, and heroin. Radiation (in amounts as low as 200 rads) can influence spermatogenesis, as can chemotherapeutic agents. Calcium channel blockers may interfere with the ability of sperm to fertilize eggs.

5. Can a vasectomy be successfully reversed?

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Yes, but the success rate is affected by the amount of time since the original vasectomy. Among patients who are less than 3 years from vasectomy, the conception rate after reversal is roughly 75%. This success rate declines to about 50% when the reversal is performed 3-8 years after vasectomy and further declines to 30% when 15 or more years have passed.

6. What is in vitro fertilization (IVF)?

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With IVF, eggs are harvested from a woman and combined with sperm in a laboratory setting. The resulting embryos are then transferred to the uterine cavity, where they mature into a fetus. In a specialized version of this technology (i.e., intracytoplasmic sperm injection), an individual sperm is injected into each egg, thus facilitating fertilization and allowing pregnancy even in the presence of small numbers of motile sperm.

7. What is the role of IVF in male infertility?

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Because use of IVF greatly reduces the number of motile sperm needed to generate a pregnancy, it can be quite helpful in men with poor semen quality. The IVF team needs only as many motile sperm as there are oocytes (eggs) to be fertilized.

8. Can sperm obtained directly from the testicle be used to generate a pregnancy?

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For the past several years, it has been recognized that incubation of testicular tissue generally yields small numbers of motile sperm. Through the use of IVF, such sperm can generate pregnancies. Even among men suffering from severe testicular failure, it may be possible to retrieve adequate sperm for use in IVF.

9. What is the role of sperm freezing in the treatment of infertility?

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Sperm can be frozen (cryopreserved) with relative ease. After they are cryopreserved, sperm remain viable for extended periods (years). Cryopreservation can be helpful among men planning to undergo treatment with chemotherapy or radiation therapy.

10. Does wearing boxer shorts versus tight underwear affect male fertility?

Show answer
No.
KEY POINTS: SURGICAL APPROACH TO INFERTILITY

1. Infertility is defined as the inability to establish pregnancy during 1 year of well-timed intercourse.
2. In 50% of infertile couples a female factor prevents pregnancy, in 30% of couples a male factor prevents pregnancy, and in 20% of couples infertility is due to a combination of both female and male factors.
3. The most common cause of male infertility is varicocele.

11. Because normal levels of testosterone are necessary for sperm production, is it helpful to give subfertile men additional testosterone?

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Although decreased levels of testosterone can cause impaired male fertility, giving additional testosterone to men with normal testosterone levels can actually cause a dramatic decline in semen quality. Administration of exogenous testosterone causes the patient to cease production of native testosterone within the testes. The resultant decrease in intratesticular testosterone actually results in a decline in sperm production.

12. What is the most common cause of male infertility?

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Varicocele, a collection of dilated veins above one or both testes. Among men presenting for treatment of infertility, 40% have a varicocele. Correction of varicocele leads to improvement in semen quality in 70% of patients.

13. If we can clone Dolly (a sheep derived from cloning a fully differentiated mammary cell), can we clone humans?

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Although for a number of critical ethical reasons cloning technology is not currently used in human reproduction, it theoretically allows the cloning of any individual, creating a genetic duplicate. However, cloning probably will not play a role in the treatment of human infertility.

14. Is IVF associated with an increase in genetic abnormalities?

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This issue is controversial, but probably no. At least one recent publication suggested that infants conceived by either intracytoplasmic sperm injection or IVF have twice the risk of major birth defects compared with naturally conceived infants.

15. Will giving supplemental testosterone improve male fertility?

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No. Exogenous testosterone induces a profound decrease in spermatogenesis and has been explored as a means of male contraception.

16. What is cloning as it pertains to humans?

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Just like Dolly the sheep, human cloning involves nuclear transplantation of the desired clone into an egg devoid of its nucleus. Rather than creating whole human beings, the more controversial ethical dilemma is whether to permit cloning of cells or organs for subsequent transplantation in order to cure human disease.

17. Are undescended testes associated with male infertility?

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Yes. Cryptorchidism is associated with male infertility. The decreased fertility correlates with severely reduced total germ cell counts in prepubertal undescended testes. Bilateral testicular maldescent does decrease semen quality. Interestingly, unilateral cryptorchidism may impair semen quality as well. This suggests that both the abnormally descended testis and its normally positioned counterpart are adversely affected. Surgical repositioning of the testis improves semen quality; the earlier it is done, the better.

References
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BIBLIOGRAPHY
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