List of VAT Registrants - The Government of The Bahamas

Jian F. Ma, MD, PhD
Chief of Urology and Ambulatory Surgery
Group Health Bellevue Medical Center
©Jian F Ma
Genitourinary Organs
 Adrenal gland
 Kidney
 Ureter
 Bladder
 Prostate
 Urethra
 Penis
 Testis/Scrotum
Adrenal Cortex Diseases
 Excessive Glucocorticoids
 Cushing



Pituitary: ACTH
Adrenal Cortex Hypertrophy
Iatrogenic
 Tests


Dexamethasone suppression test
Saliva cortisol test, equally effective, approved by FDA
Adrenal Cortex Diseases
 Insufficiency (Addison’s Disease)
 Chronic
 Acute: life threatening!!!


Adrenal hemorrhage in pregnancy
Stress dose of steroid during surgery or trauma
Adrenal Medulla Diseases
 Pheochromocytoma
 Episodic hypertension, arrhythmia
 Can be familial (25%): MEN 1, MEN 2 etc
 Diagnosis: Plasma metanephrine (most accurate)
 Imaging: MIBG
Adrenal Medulla Diseases
 Treatment
 Phenoxybenzamine
 Surgery:



Laparoscopic or open adrenalectomy
Very high intraoperative risk of vascular collapse
Only done in specialized centers
Adrenal Malignancy
 Rare: 1-2 per million
 Can be hormonally active
 Early metastasis
 Treatment
 Surgery
 Radiation (palliative)
 Chemotherapy: mitotane (metastatic)

Derivative of DDT
 Prognosis: Poor, 25% five-year survival
Benign Renal Pathophysiology (Urology)
 Obstruction (hydronephrosis)
 Infection/inflammation
 Nephrolithiasis
Renal Obstruction: Definition
Whitaker Test
10 mm H2O is physiologic
23 mm H2O or above is obstructive
Renal Obstruction
 Ureteral
 Congenital
 Stone
 Cancer
 Stricture (post surgical, trauma, radiation)
Renal Obstruction: How to unobstruct
 Stent
 Nephrostomy
Renal Obstruction
 Ureteropelvic Junction
 Mostly congenital
 Dietl’s Crisis
 Management


Stent, nephrostomy
Laparoscopic (open) Pyeloplasty
Renal Obstruction: Treatment
Treatment of stone/tumor
Incision: laser, electrical, knife
Dilation
Excisional Repair
Ureteroureterotomy
Distal reimplantation
Auto transplantation
Nephrectomy:
Function less than 15-20%
Symptomatic
Renal Infection
 Pyelonephritis
 Cx: usually more ill than cystitis, may progress to
urosepsis (may deteriorate explosively to ARDS in
hours)
 Urine and blood culture
 Rule out obstruction: immediate drainage

Ultrasound, CT, MRI, Diuretic Renogram, Retrograde
Pyelogram
 IV broad spectrum antibiotic, then switch to culture
appropriate po antibiotic, total of 2 weeks therapy
Renal Infection
 Obstructive Pyelonephritis
 From obstructive stone or stricture/injury
 Medical therapy usually not sufficient until the
obstruction is treated (stent, nephrostomy)
 If workup is delayed, may progress to urosepsis

Poor outcome, medicolegal risk
Nephrolithiasis
 Common illness:
 15% prevalence
 $3 billion in 2003 in US

Indirect cost far more than $3B
 Hippocratic Oath
 Do no harm

“I will not use the knife, not even on sufferers from stone, but
will withdraw in favor of such men as are engaged in this work”
Nephrolithiasis: symptoms
 Nephrolithiasis usually is asymptomatic
 Renal colic from obstruction when the stone migrates
to ureter
 The level of pain
 Nausea and vomiting
 From hollow viscus obstruction
 Obstructive pyelonephritis
 Fever and chills
 Hypotension
Nephrolithiasis: Size and Location
 Average caliber of the ureter 5-6 mm
 2 mm 80% chance of spontaneous passage
 5-6 mm 50%
 8 mm 20%
 Locations
 UPJ
 Iliac crossing
 UVJ
Nephrolithiasis: Indications for Intervention
 Management of Obstruction: stent, NT
 Obstructive pyelonephritis: fever, chills etc
 Dehydration from vomiting
 Poorly controlled pain
 Surgical Intervention: lithotripsy
 Failure to progress
 Unable to tolerate stent, nephrostomy tube
 Large size, proximal location
 Special circumstances

Commercial pilots, captains, fire/policemen, drivers etc
Nephrolithiasis
 Stone composition
 Majority: calcium oxalate (monohydrate and dihydrate)

Mostly dietary and hydration related
 Calcium phosphate

Metabolic acidosis
 Uric acid


Dietary, gout, “disease of the kings”
Alkalinization: baking soda, potassium citrate
 Struvite (magnesium ammonium phosphate)
 UTI related (urea splitting organism)
Nephrolithiasis: Risk Factors
 Family history
 Profession
 Limited fluid intake
 Weather
 Dehydration
 Medical conditions
 IBD, Crohns, UC
 Gastric bypass, short gut
 Parathyroid
 Sarcoid etc
Nephrolithiasis: Dietary Factors
 The single most important contribution
 Sodium, protein, fat “rich food”
 Pediatric stones
 From “rare” to “common” in the last several decades
 Strong correlation with obesity, cardiovascular disease
and diabetes
Nephrolithiasis: Prevention
 Dietary/behavioral change
 Hydration (3 liters per day)
 Low sodium, low protein food
 DASH (dietary approach to stop hypertension) Diet
 Lemon juice: citric acid
Kidney Cancer (parenchymal)
 Type
 Clear cell (most common), papillary, chromophobe etc
 Stage
 Can form tumor thrombus and extend through vena
cava all the way to the right atrium
 Metastasis: nodal, lung, bony, hepatic
Kidney Cancer (parenchymal)
 Treatment
 Surgery: only curative therapy
 Chemo: not effective
 Immunotherapy and radiation only palliative
 Surgery
 Total nephrectomy (laparoscopy, open)
 Nephron sparing (partial nephrectomy)
 Minimally invasive therapy: unproven durable result

For patients with inability to tolerate radical surgery or limited
life expectancy
Kidney Cancer (urothelial)
 Transitional (same as bladder cancer)
 5% of the bladder cancer patients may develop upper
tract transitional cell carcinoma
 Treatment
 Endoscopic for small, solitary lesion
 Nephro-ureterectomy for large, multifocal, invasive
tumor
Benign Renal Tumor
 Cyst: Defined by complexity, not by size
 Bosniak 1-2: no follow-up
 Bosniak 2F: follow up
 Bosniak 3-4: surgery
 Angiomyolipoma
 May cause spontaneous bleeding (in pregnancy)
 Surgery for over 4 cm (angio-ablation, partial nephrectomy)
 Oncocytoma
 Solid tumor
 Diagnosed after nephrectomy
Bladder
 Storage of urine
 Normal adult: about 500 ml (about 5 hours of urine)
 Can be as big as 1 liter (under anesthesia)
 Detrusor (smooth muscle)
 Passive during storage
 Active during micturition
 Post void residue (PVR)

Should be zero in a young man
Bladder
 Failure of storage
 Urgency, urge incontinence


Idiopathic (overactive bladder)
Neurogenic: CNS
 MS, post stroke, spinal cord
 Failure of emptying
 Retention, atonic bladder
Anatomic: prostatic or urethral obstruction
Neurogenic: CNS/PNS
MS, spinal cord injury, pelvic surgery/injury
Bladder: Failure of storage
 Rule out neurogenic problem
 Most common back problem
 Medical treatment: anticholinergic
 Major side effects: dryness, constipation, poor
compliance
 Contraindication: close angle glaucoma
 Surgical treatment
 Botox: needs reinjection every 9-15 months, just like the
face
 Interstim (sacral pacemaker)
Bladder: Failure of emptying
 Catheterization
 Indwelling vs self catheterization
Benjamin Franklin developed a flexible
urinary catheter that appears to have
been the first one produced in America.
But his relationship with his patient (his
brother James) was not as friendly, and
Ben was forced to escape his abusive
brother to go to Philadelphia.
Bladder: Failure of emptying
 If possible, intermittent catheterization is preferred
 Less infection (no foreign body long term)
 More patient comfort (no constant penile irritation)
 The patient may still void in between
 Suprapubic catheterization
 No penile irritation
 UTI risk same as penile catheterization
 Requires minor anesthesia, small risk of bowel injury
Bladder: Failure of emptying
 α-blocker
 Prazosin (Minipress), terazosin (Hytrin), doxazosin
(Cardura), tamsulosin (Flomax), alfuzosin (Uroxatrol),
silodosin (Rapaflo)
 Side effects
 Orthostatic hypotension
 Retrograde ejaculation
 Floppy iris syndrome (during cataract surgery)
Bladder: Failure of Emptying
 Surgery: to open the obstruction
 Stricture (endoscopic, open repair)
 Enlarged prostate
 Prostate surgery
 Prostatic incision
 Minimally invasive therapy: microwave, etc
 Laser procedure (greenlight)


New but not necessary gold standard, outpatient surgery
Re-operation rate 28%
 Transurethral Resection of the Prostate (TURP)
 Gold standard: re-operation rate 3-5 % per year
Bladder: UTI
 Risks
 Fecal-vaginal colonization
 Urinary stasis (from bph, stricture, neurogenic bladder)
 Foreign body (stone, catheter)
 Treatment: only bph, stricture and stone can be
treated surgically, the rest medically
Bladder: UTI
 Urine culture (not urine analysis)
 Asymptomatic bacteriuria DOES NOT require
treatment
 Please don’t culture old ladies in SNF without symptoms
 Culture sensitive antibiotic
 Prophylaxis: very low dose of antibiotic
 Natural prophylaxis
 Cranberry
 Probiotic: fecal-vaginal colonization with friendly
bacteria
Bladder Cancer
 50,000 new cases per year
 Risk factors
 Smoking (tobacco, marijuana), chemical exposure, prior
radiation, chemo (cyclophosphamide)
 ?Actos
 Field defect: the entire urothelial surface at risk
 At diagnosis
 85% localized, 38% muscle invasive
 15% metastatic
Bladder Cancer: Superficial Cancer
 Ta (subepithelial): resection
 T1 (lamina propria)
 Resection, intravesical chemotherapy (mitomycin)
 Adjuvant immunotherapy (BCG, mitomycin etc)
 CIS: unpredictable behavior, disease progression
 BCG, BCG plus interferon
 Cystectomy uncommon (4,000 vs 50,000 new cases)
 For multifocal, recurrent, persistent disease
 Recurrent, persistent CIS
 Non-compliance
Bladder Cancer: Invasive
 T2, T3: radical cystectomy
 T3-4: palliative cystectomy (for bleeding, urinary
diversion, local symptoms etc)
 Urethrectomy
Hematuria Workup
 Gross hematuria (flank hematuria)
 Microscopic hematuria
 Old def: 3 RBC/hpf in 2/3 UA
 New def: 3 RBC/hpf in ONE UA (no dip)
 Patients on anticoagulant: still need workup
 Upper tract study
 Multiphase CT, MR
 Ultrasound less optimal, no body radiation
 Lower tract study
 Cystoscopy
Prostate: BPH
 BPH
 Anatomic definition
 Happens to EVERY MAN if he lives long enough
 No treatment unless symptomatic (LUTs, or lower
urinary tract symptoms)
Prostate Cancer
 Epidemiology
 About 300,000 new cases, 30,000 deaths

breast cancer 39,000 deaths
 Late patients very symptomatic



Bone pain, kidney and bladder obstruction
It takes a long time to die (5-8 years not uncommon)
Very debilitating, and costly
Prostate Cancer
 Screening
 How to diagnose the lethal kind of cancer


Before 1985, DRE alone, mostly advanced stage cancer
PSA era, mostly early cancer, mortality decreases by 40%
 Also over-treatment, side effects
 Other markers not widely adopted (PCA3 etc)
 Controversial
 USPTF: grade D (do not recommend)
 So far very few organizations choose to follow
 Obama got his PSA three times (age 46, 48, 50), most recently
Sept 2011, after USPTF recommendation
 Canada does not pay for screening PSA (but pays for prostate cancer
treatment)
Prostate Cancer
 Screening consensus for now
 Life expectancy 10 years or more


40-75
Reasonably good health
 High risk population


African American
Family history
 PSA and DRE
 Things may change after 2014
 Canadian model?
Prostate Cancer
 Diagnosis
 Prostate biopsy

Transrectal, transperineal
 Well tolerated
 3-5% of urosepsis (bacterial prostatitis), usually because of
resistant bacteria
 10-12 cores
 Additional studies


CT for pelvic adenopathy
Bone scan: only useful in PSA over 20
Prostate Cancer
 Prognosis
 Biopsy finding

Higher Gleason Scores (4 or 5)
 Nomogram
 D’Amico
Prostate Cancer: Treatment
 Watchful waiting
 For low and intermediate risk groups
 Serial PSA, periodic bx to monitor disease progression


No treatment side effects
Unpredictable disease progression
 Expect more in the future


The right thing to do?
Cost?
Prostate Cancer: Treatment
 Surgery
 Open surgery


Radical retropubic prostatectomy
Perineal prostatectomy
 Laparoscopic w/wo robotic assistance
 Overall no difference

Side effects: SUI, impotence
Prostate Cancer: Treatment
 Radiation
 External Beam Radiation (including proton beam),
brachytherapy (seeds)

No difference
 Side effects



Still has a prostate (obstruction, bleeding etc)
Rectal, bladder, urethral injury
Secondary pelvic malignancy (8% life time risk)
 Bladder, rectum
Prostate Cancer: Treatment
 Cryotherapy
 HIFU (high intensity focal ultrasound, not approved in
US)
 Like brachytherapy

May have significant local side effects
Prostate Cancer: Treatment of Metastasis
 Hormone deprivation therapy
 Castration controls the growth of prostate cancer graft


Nobel Prize 1966 (Huggins)
Surgical castration, chemical castration
Nobel Prize 1977
Guillemin, Schally
Prostate Cancer: Metastasis
 Hormone deprivation therapy
 Castration, LHRH agonist, antagonist
 Antiandrogens
 Adrenolytic agents, steroid
 Immunotherapy
 Chemotherapy
 Palliative radiation for bone pain
 Other supportive measurements
 Nephrostomy, suprapubic tube
 Channel TURP
Urethra
 Stricture
Urethral Stricture
 Causes
 Injury (trauma, instrumentation, radiation/laser/cryo)
 Inflammatory (STD)
 Symptoms
 Similar to Luts in elderly men
 Younger age, history
 Treatment
 Endoscopic incision, dilation
 Open repair, primary vs buccal mucosa graft
Hypospadias
 Urethral opening not at the tip
 Neonatal exam
 Not life threatening, elective referral
 UNLESS NO GONADs


Congenital adrenal hyperplasia
Salt wasting form, life threatening
 Urinary stream, infertility (proximal)
 Repair
 Usually after 6 months (safer anesthesia)
Phimosis
 Physiologic
 Circumcision
 79% in 1980, 55% in 2010
 Washington State: 25%
 Neonatal circ at bedside, after 1-2 week with anesthesia
 Pros: uti (in young children), balanitis, viral infection
transmission (hiv, herpes, hpv, including risk in women)
 Penile cancer


0% in Israel (near 100% cir), 0.2/100,000 in US (80% circ)
Highest in India 3.3/100,000 and Brazil 6.8/100,000
Phimosis: Debate
 AAP: Health benefits of circumcision outweigh the
risks (2012)
 Declining circumcision rates may add $4 billion in U.S.
health care costs (CBS News, 2012)
 A German court decides that ritual circumcision
amounts to criminal bodily harm, fear of national ban
 San Francisco Male Genital Mutilation Ballot
 “Inactivitist Movement”
Erectile Dysfunction
 Mechanism of erection
 Vascular
 Parasympathetic nervous system
 Mechanism of ED
 Arterial insufficiency: atherosclorosis
 Venous insufficiency: venous leak
 Nerve damage


Peripheral neuropathy: DM, pelvic surgery/radiation, etc
Central: spinal cord injury
Erectile Dysfunction: Treatment
 Medical Therapy
 PDE5 inhibitor (Viagra, Levitra, Cialis)


Increase arterial flow
Contraindications: nitro, retina
 Prostaglandins


Penile injection
Transurethral suppository
 Vacuum device
Erectile Dysfunction: Treatment
 Surgical Therapy
 Pros


Highly effective
Satisfaction rate 90% +
 Cons



Surgery-anesthesia
Complication
 Infection
 Malfunction
Cost $20,000+, self pay
Penile Cancer
 Etiology
 HPV
 Uncircumcised state
 Treatment
 Small, superficial lesion

Local treatment
 Large, deep, higher grade cancer


Partial vs total penectomy (with perineal urethrotomy)
Lymph node dissection
 Chemotherapy, radiation therapy palliative
Testis: Cryptorchidism
 Function
 Spermatogenesis (requires a lower temp 35 ˚C)
 Hormone
 Cryptorchidism
 40% premie, 3% term, 1% at 1 yo
 Observation
 Surgery at 1 year
 Bilateral cryptorchidism AND
Hypospadias: rule out salt wasting intersex
Testis: Torsion
 Ischemia due to volvulus of the cord
 Usually in young men
 Sudden onset of pain

Can have intermittent torsion
 Testis can survive for 6 hours

Not salvageable after 24 hours
 Diagnosis



Physical exam
Doppler ultrasound
If clinically suspicious, scrotal exploration

Testis: Benign Scrotal Mass
 Hydrocele and Spermatocele
 Only symptomatic masses require Rx
 Hydrocelectomy: 15% recurrence
 Aspiration: 100% recurrence
 Varicocele
 Common in young men: 15% of army recruits
 Indications for therapy (varicocelectomy or
embolization)


Pain, arrested testis growth, infertility
Testis: Infertility
 Definition
 Unable to conceive after one year of unprotected sex
 15% of couples infertile,

30% male factor, 40% female., 30% both
 With modern technology, almost all couples can
“reproduce”
 Male factors
 Post vas
 Varicocele
 Other factors: mumps, smoking, prior chemo-radiation
Testis: Vasectomy
 Procedure
 Most done as an outpatient procedure
 Cost: between “free” to $4,000
 Short recovery, no permanent deficit (including sexual),
no future cancer
 Semen test: azoospermic (only 30% back for test)
 Complications
 Hematoma, infection
 Post Vas Pain Syndrome (PVPS)


Can happen years later
From epididymal congestion
Testis: Vasectomy Reversal
 Procedure
 8% are reversed
 Effective 70%
 Almost no insurance coverage (except Microsoft,
Amazon, Starbucks)
 Cost: $10,000 to $20,000
 Occasionally done for PVPS
Testosterone Supplement
 ADAM: Androgen Deficiency in Aging Males
 Symptoms


Low energy, libido, physical abilities
Low or low-normal serum testosterone level
 Unlike "menopause", the word "andropause" is not
currently recognized by the World Health Organization
and its ICD-10 medical classification
Testosterone Supplement
Testosterone Supplement: FDA
 Testosterone is indicated for replacement therapy in the
male in conditions associated with symptoms of
deficiency or absence of endogenous Testosterone



Primary hypogonadism (congenital or acquired)-testicular failure due to
cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome; or
orchidectomy.
Hypogonadotropic hypogonadism (congenital or acquired)-idiopathic
gonadotropin or LHRH deficiency, or pituitary-hypothalamic injury from tumors,
trauma, or radiation.
Testosterone Supplement: FDA
 Contraindications
 Known hypersensitivity to the drug
 Males with carcinoma of the breast
 Males with known or suspected carcinoma of the
prostate gland
 Women who are or who may become pregnant
 Patients with serious cardiac, hepatic or renal
disease
Testis: Cancer
 Presentation
 Young men, 8,000 per year in US
 Painless mass
 Ultrasound
 Seminoma most common
 Nonseminomatous germ cell tumor NSGCT more
dangerous
 Staging workup


Serum markers: β-hcg, AFP, LDH
CT of the chest and retroperitoneum
Testis Cancer
Scrotum and Perineum: Fournier’s Gangrene
 Necrotizing infection
 Named after Jean Fournier, first described in 1764

5 previously healthy young men suffered from a rapidly
progressive gangrene of the penis and scrotum without
apparent cause.
 Can happen at any age, more in immune-compromised
population (DM, steroid, morbid obesity etc)
 Mortality rate near 50%
Fournier’s Gangrene
 Presentation
 Both aerobic and anaerobic bacteria
 Blistery, bubbly/rice crispy (gas gangrene), not
necessarily purulent
 Rapidly progressing erythema line (up to one inch per
hour)
 Treatment: Surgical debridement, abx, supportive
`