UROLOGIC TREATMETS
RENAL COLIC
• Small stone (<1cm), no infection – medical treatment (max. 6 weeks—> surgery)
• Large stone (>1cm), no infection – surgery
• Any size, infection – Kidney decompression: Double J stent or percutaneous nephrostomy +
Antibiotics (min 3 days without fever)
ACUTE URINARY RETENTION
• Lower tract obstruction: CATHETERISATION – FOLEY CATHETER.
• Upper tract, solitary kidney or bilateral obstruction: PERCUTANEOUS NEPHROSTOMY or
DJ URETERAL STENT.
GROSS HEMATURIA
• Conservative management:
- Check blood morphology
- Couvelaire catheter
- Cystoscopy
- TURB - transurethral resection Bladder
- TURP - transurethral resection Prostate
• Electrocoagulation if conservative management is not successful in bleeding control
• Embolisation of vessels in bleeding kidney tumor
PRIAPISM
Surgery (shunt)
FOURNIER GANGRENE
• Antibiotic and Antifungal Therapy I.V
• Surgical Diagnosis and Debridement: perineal fascial compartment opening
• Excising necrotic tissue
• Reconstruction: skin grafts
• Hyperbaric Oxygen Therapy : support
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STRESS URINARY INCONTINENCE
excercises —> surgery (drugs if surgery is contraindicated)
• Conservative management (1st line)
- There is association between UI and constipations, but no data that constipation treatment
improves UI.
- Lifestyle (sport and diet).
- Physical therapy (pelvic floor exercises).
• Pharmacological
- Duloxetine
- Vaginal oestrogens (LOCAL)
• Surgical
- Mid-urethral slings (MUS) + common; Transobturator route (TOT) or retropubic route
- Success rate >95%
- Complications:
Pain
De novo OAB (De novo overactive bladder)
Tape erosion
Urinary retention
- Other:
Colposuspension both laparoscopic or open
-
Bulking agents
-
Artificial urinary sphincter (Best solution to treat SUI in men)
URGENCY URINARY INCONTINENCE pharmacotherapy —> surgery
• Pharmacological
- Anticholinergics: 1st choice in drug treatment of OAB and UUI.
- Beta-3 adrenergic receptor agonist (Mirabegron).
• Botulinum toxin: 3rd line (inconvenient: detrusor underactivity—> intermittent catheterization).
• Sacral neuromodulation: electrodes in S3 foramen (no detrusor underactivity).
• Surgical
- Augmentation cystoplasty (with intestine).
- Urinary diversion (new way for urine-bypass).
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NEUROGENIC BLADDER
Intermittent Catheterization
RENAL TRAUMA
• 80% Conservative (maximal conservation of tissue and function)
- STABLE PATIENTS: BLUNT grade 1-3 / PENETRATING only isolated
- Reposo en cama, controlar FR - FC, evaluar el hematoma con ECO (semana 6 y 12),
Intravenous Pyelogram (IVP) an x-ray (semana 12) y control de Presión Sanguínea durante
mínimo 12 meses.
• Endourologic treatment
- BLUNT grade 4 / Persistent extravasation / Urinoma
- Drainage
- JJ stent / nephrostomy
- Antibiotic
• Early surgical treatment
- BLUNT grade 5
- Most penetrating / gunshot
- Shock / unstable
- Expanding, pulsatile hematoma
• Late surgical treatment
- Late hemorrhage / unstable / complications
URETIC TRAUMA
• Early diagnosis (5-7 days) if not avulsion (only grade 1-4)
- Early surgical repair
- Curative JJ stent / nephrostomy
• Late diagnosis (10-14 days) or infected
- Always drainage
- JJ stent/nephrostomy for 6 weeks
- Radiological evaluation (IVP, pyelography)—> ¿Cured or delayed surgery?
‣ Upper ureter: end-to-end anastomosis, ileal repair, transureter-oureterostomy, autotransplantation.
‣ Mild or lower ureter: ureterocystoneostomy with/without psoas hitch / Boari ap.
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BLADDER TRAUMA
• Surgical repair as a rule.
• Conservative in small extraperitoneal ruptures: catheter 10 days + cystography.
URETHRAL TRAUMA
• Anterior trauma
- Contusion, partial: catheter + 2 weekly urethrography until healed (to take out the catheter).
- Complete:
‣ SPT (Suprapubic catheter tube - Foley catheter)
‣ Emergency anastomosis + hematoma drainage.
‣ Delayed anastomosis
• Posterior trauma
- SPT !!!
- Partial = Anterior trauma
- Complete = delayed anastomosis at 3-6 months (after SPT).
PENILE TRAUMA
• Tunica albuginea rupture (penile fracture): emergency surgery.
• Dislocation: surgery.
• Strangulation with foreign body: emergency removal of foreign body.
• Contusion (hematoma): conservative.
SCROTAL AND TESTICULAR TRAUMA
• US - Hematoma: always emergency surgery (risk of ischemic testicular atrophy + infection).
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UROLITHIASIS
• Observation: in asymptomatic lower pole kidney stone in comorbid patients.
• Medical expulsion therapy (MET) - Alpha adrenolytics (Tamsulosin)
- Drugs for ureter relaxation
- For stones that are likely to be expelled (<6 mm / <0.6 cm)
- Systematic observation of patients (por si hay complicaciones: fever, recurrent pain or renal
function deterioration).
• Extracorporeal shock wave lithotripsy (ESWL) Pressure changes up to 40 MPa.
- Radiopaque stone
- <20 mm / <2 cm in kidney
- All sizes in ureter
- Contraindications:
‣ Pregnancy
‣ Untreated UTI
‣ Untreated coagulation disorders
‣ Aortic or renal aneurysm
‣ Stricture below the stone
• Uretero-renoscopic lithotripsy (URSL) Endoscopy through the urethra, bladder and ureter.
- Holmium laser + forceps or baskets
- Often need to put JJ stent post-URSL
- Ureteral Stones >10 mm / >1 cm
• Flexible uretero-renoscopic lithotripsy (fURSL) or Retrograde intrarenal surgery (RIRS)
- Uretero beroscope: can access stones in kidney pelvis and calices.
- Kidney stones <2cm
• Percutaneous nephrolitotomy (PCNL) By a small puncture.
- >20 mm / >2 cm in kidney
- Contraindications:
‣ Pregnancy
‣ Untreated UTI
‣ Untreated coagulation disorders
‣ Renal tumor
‣ Morbid obesity or severe skeletal deformities
• Laparoscopic and open surgery (no se usa mucho hoy en día).
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RENAL COLIC
• Las piedras de <5 mm (0,5cm) pasan solas sin intervención: analgesics + antiemetic.
• In analgesic-refractory pain consider renal decompression (drainage) or ureteral stone removal
- Distal ureter stones >5 mm: MET (Medical expulsive therapy).
- In proximal ureter stones or kidney stones: los procedimientos del apartado anterior.
BLADDER STONES
• Secondary stones (due to Benign prostatic enlargement) are unlikely to pass spontaneously
and are mostly symptomatic - require treatment
- Trans-urethral cystolithotripsy (can be combined with Transurethral resection of prostate-TURP)
- Suprapubic cystolithotomy: open procedure for big stones.
- Percutaneous cystolithotripsy in children.
PROSTATE CANCER (adenocarcinoma)
• Localized and locally advanced cancer: curative.
- Surgery: radical prostatectomy
- Radiotherapy (results as good as after radical prostatectomy)
- Brachy
- Aggressive cancer: surgery + radiotherapy
• Life expectancy <10 years, not suitable or patient’s choice: palliative (Hormonal, radiotherapy)
• Metastatic (Hormonal, chemotherapy)
- Anti-androgenes (steroid or non-steroid).
- Castration (surgical or pharmacological with LHRH analogues).
- MAB (Maximal androgen blockade: anti-androgens + castration).
RENAL CELL CARCINOMA (clear cell carcinoma)
• Localized tumor
- Partial nephrectomy (nephron-sparing surgery - NSS): elective - generally for <7 cm.
- Radical nephrectomy if partial is not possible.
• Locally-advanced tumor
- Radical nephrectomy
• Metastatic
- Chemotherapy (ineffective in clear cell carcinoma (RCC))
- Immunotherapy
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BLADDER CANCER (urothielial carcinoma)
• Non-muscle invasive bladder cancer (NMIBC)
- TURT — Transurethral resection of tumor (resection + pathological assessment: grading
and staging).
• High risk NMIBC
- TURT + adjuvant
• Muscle invasive bladder cancer (MIBC)
- Radical cystectomy (+ neoadjuvant/adjuvant chemotherapy)
TESTICULAR CANCER (germ cell tumor)
Radical orchiectomy + chemotherapy
BENIGN PROSTATIC HYPERPLASIA
• Conservative: watchful waiting for men with non-bothersome LUTS.
• Pharmacological
- α1-adrenoceptor antagonists (α1-blockers)
[alfuzosin, doxazosin, silodosin, tamsulosin, terazosin, naftopidil]
- 5α- reductase inhibitors
- phosphodiesterase 5 inhibitors (PDE5Is)
- muscarinic receptor antagonists
- beta-3 agonist
- Combination therapies
‣ α1-blockers + 5α-reductase inhibitors
‣ α1-blockers + muscarinic receptor antagonists
• Surgical
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