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RH33 Rheumatology Toronto Notes 2023

Trial Name Reference Clinical Trial Details

Irealment o> Active Rheumatoid Arch Intern Med

Arthritis with leflunomide

Compared with Placebo and

Melhotrexale.Leflunomide

Rheumatoid Arthritis

Investigators Group. Strand et

al.1999

Title: Treatment of Active Rheumatoid Arlhrilis with lellunomidc Compared with Placebo and Metholrcialc. leflunomide Rheumatoid

Arthritis Investigators Group

Purpose:lo compare the safely and efficacy of leflunomide vs. MIX in patients with active RA.

Methods:482 patients with active RA were randomly assigned to receive leflunomide (20 mg/d). MIX (7.5-15 mgi'wk).or placebo.

Results: Clinicalresponse and success rales on leflunomide |S2% and 41%) and MIX (46% and 35%) were significantly greater than

those on placebo (26% and 19%) (P'

0.001). On leflunomide. common adverse events included gastrointestinal complaints, shin rash,

and reversible alopecia.

Conclusion:In patients with active RA.leflunomide was associated with better clinical responses than placebo and had similar

efficacies as MIX.

Title: Ihc PRiMIER Study:a Multicenter. Randomiied. Double Blind Clinical Trial of Combination Therapy with Adalimumabplus

Melhotreiale versus Methotrexate Alone or Adalimumab Alone in Patients with Early. Aggiessive Rheumatoid Arthritis Who Had Not Had

Previous Methotrexate Treatment

Purpose:To compare the efficacy and safety of adalimumab plus MIX versus MIX alone or adalimumab alone in patients with early,

aggressive RA who were MTX-naive.

Methods: 799 patients with active disease -3 yr were randomly assigned lo adalimumab 40 mg SC every other wk plus oral MIX.

adalimumab 40 mg SC every other wk,or oral MTXweekly.

Results: American College of Rheumatology 50% improvement was achieved in significantly more patients on combination therapy

(62%) than MIX or adalimumab (46% and 41%,respectively;both P'

0.001). Patients on combination therapy had significantly less

radiographic progression (P'

0.002) than those on cither monotherapy. 49% of patients on combination therapy achieved remission at

1999:159:2542 50

PREMIER Arthritis Rheum

2006:54:26 37

2 yr.

Conclusion: Adalimumab plus MIX was significantly superior to either MlX or adalimumab alone in early, aggressive RA .

OSTEOARTHRITIS

Ann Rheum Dis

2010:69:1097-1102

Title: Intra Articular Hyaluronan is without Clinical Ellecl in Knee Osteoarthritis: a Multicenlre, Randomised. Placebo Controlled.

Double Blind Study of 337 Patients Followed for 1Year

Purpose:To assess the long-term safety and efficacy of 5 hyaluronan 1A injections in knee osteoarthritis.

Methods:337 patients with knee osteoarthritis and a lequesne algofunctional index score (LFI) »10 received IA hyaluronan product

(sodium hyaluronate;Hyalgan *

) or saline weekly for 5 wk.

Results: Treatment had no significant effedon time lo recurrence or baseline change in LFI or walking pain. There were also no

significant differences in paracetamol consumption,patients' global assessment,responder rales,or adverse events.

Conclusion:Hyaluronan injections were not clinically effective in patients with osteoarthritis of the knee with moderate-severe

disease (LFI>10).

Hyaluronan

SYSTEMIC LUPUS ERYTHEMATOSUS

8e!imumab Lancet 2011:377:721 31 Title: Efficacy and Safely of 8elimumab in Patients with Active Systemic Lupus Erythematosus:a Randomised. Placebo-Conlroiled.

Phase 3 Trial

Purpose: To assess the efficacy and safely of belimumab in patients with active SLE.

Methods: 867 patients (aged >18 yr) who were seropositive with scores of > 6 on SELENA SIEDAI were randomly assigned lo belimumab

1mg/kg or 10 mglkg. or placebo plus standard of care (based on disease manifestation and local guidelines).

Results: Significantly higher SRI (SLE Responder Index)rates occurred with belimumab1mg/kg (51%.OR 1.55;P'0.0129) and 10 mg/kg

(58%, 1.83;P‘

0.0006) than placebo (44%).There was a greater frequency of SELEHA-SLEDAI reduction by >4 points with belimumab1

mg/kg [53%, 1.51; P‘0.0189) and 10 mg/kg (58%.1.71:P‘0.0024) than placebo (46%).

Conclusion: Belimumab may be the lirst targeted biologic that is specifically approved for SLE.

Title: Mycophenolate Mofetrl or IntravenousCydophosphamide for Lupus Nephritis

Purpose:To investigate if mycophenolate mofelil is effective for treating lupus nephritis.

Methods: 140 patients with active lupus nephritis were randomly assigned to oral mycophenolate moletil (1000 mgld increased to

3000 mgfd) or monthly IV cyclophosphamide (0.5 g/m2 increased to 1.0 g/m'

),

Results: 22.5% of patients on mycophenolate mofelil and 5.8% of those on cyclophosphamide experienced complete remission

(absolute difference.16.7%:95% Cl.5.6-27.9%:P'0.005),thus demonstrating thatmycophenolate mofetil is more efficacious than

cyclophosphamide.

Conclusion: In active lupus nephritis,mycophenolate mofetil wasmorc effective than IVcyclophosphamide in inducing remission and

had a belter safely profile.

Mycophenolate Mofetil or

Intravenous Cyclophosphamide

for lupus Nephritis.Gimlet et

at.2005

NEJM 2005:353:2219-28

CONNECTIVE TISSUE DISORDERS

NEJM 2008:359:2790-803 Title: Arathioprine or Methotrexate Mainlenancefor ANCA- Associated Vasculitis

Purpose: To compare malhioprine (A2A) and MIX lor safely and efficacy in Wegener's granulomatosis and microscopic polyangiitis.

Methods: 159 patients who achievedremission with IV cydophosphamtde and corticosteroids were randomly assigned to receive oral

AZA orMIXfor 12 mo.

Results:The rates of adverse events (requiring discontinuation of the study drug or causing death) were not significantly different

between groups. Event- free survival was also not significantly differentbetween groups.

Conclusion:In patients wilh Wegener's granulomatosis and microscopic polyangiitis. AZA and MIX are similar alternatives lor

maintenance therapy after initial remission.

Title: Pulse versusDaily Oral Cydophosphamidefor Induction of Remission in Antineutrophil Cytoplasmic Antibody-Associated

Vasculitis:a Randomiied Trial

Purpose: Tocompare Ihc efficacy of pulse cyclophosphamide vs. daily oral cyclophosphamide for inducing remission in ANCA

associated vasculitis.

Methods:149 patients with newly diagnosed generalized ANCA-assodated vasculitis with renal involvementreceived

cyclophosphamide 15 mg/kg every 2-3 wk (pulse), or daily cyclophosphamide 2 mg/kg orally,plus prednisolone.

Results:Ihere was no significant difference in lime lo remission |P‘

0.59) or percentage of patients who went into remission at 9 mo

(88.1% in pulse vs. 87.7% in oral). The oral group had higher cumulative cyclophosphamide doses|P'

0.001). Lower rates ol leukopenia

were seen in the pulse group (hazard ratio.0.41; 95% Cl.0.23 to 0.71).

Conclusion:In ANCA-associated vasculitis,pulse cyclophosphamide induced remission as effectively as the daily oral regimen,

required less cumulative cyclophosphamide, and caused lewer cases of leukopenia.

NEJM 2006:354:2655 66 Title: Cyclophosphamide versus Placeboin Scleroderma lung Disease

Purpose: Todetermine the efficacy of oral cyclophosphamide in patients with active alveolitis and scleroderma-related ILD.

Methods:158 patients with scleroderma,restrictive lung physiology,dyspnea, and evidence of inflammatory ILD received oral

cyclophosphamide|s2mg/kg/d) or placebo for 1yr.

Results: Ihe mean absolute difference in 12 mo adjusted FVC between cyclophosphamide and placebo was 2.53% (95% Cl. 0.28 lo

4.79%), indicating great efficacy ol cyclophosphamide (P'

0.03). The dillerence in FVC belwcen groups was sustained at 24 mo.

Conclusion: In patients with symptomatic scleroderma-related ILD.oral cyclophosphamide had significant clinical benefit.

Aialhioprine or Methotrexate

Maintenance for ANCA -

Associated Vasculitis. Pagnoux

et al. 2008

CYCLOPS Ann Intern Med

2009:150:670 80

r->

L J

Cyclophosphamide vs. Placebo

in Scleroderma Lung Disease.

Tashkin et al. 2006

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RH31 Rheumatology Toronto Notes 2023

Trial Name Reference Clinical Trial Details

HEJM 2005;352:351- 361 Title: Etanercept plus Standard Therapy lor Wegener's Granulomatosis

Purpose: to investigate the solely and etficocy of etanercept for remission maintenance In GPA

Methods:180 patients with GPA were randomly assigned to receive either etanercept or placebo,in addition to standaid treatment

(glucocorticoids plus cyclophosphamide or MIX).

Results:Ho significant differences were observed between the etanercept and control groups in the rates of stable periods of low-level

disease activity|86.5% vs. 90.6”

»,p-0.32). sustained remission (69.7% vs.75.3%. P‘

0.39).or the time necessary to reach those

outcomes. Oisease flares and adverse events were common in both groups but not significantly different.

Conclusion:Etanercept isnot effective for remission maintenance inGPA.

Title:Mycophenolate Mofetil versus Acathiopnne for Remission Maintenance inAntineutrophil Cytoplasmic Antibody-Associated

Vasculitis (AAV):a Randomized Controlled Trial

Purpose:To compare the efficacy of mycophenolate mofetil vs.arathioprine (A2A) preventing relapses inpatients with AAV.

Methods:following remission induction with cyclophosphamide and prednisotone.156 patients with newly diagnosed AAV were

randomly assigned to A2A (initiated at 2 mg

'

kg/d) or mycophenolate mofetil (initialed at 2000 mg/d|.

Results:The mycophenolate mofetil group experienced significantly more relapses (55%) as compared to A2A (37.5%) (hazard ratio

for mycophenolate mofetil.1.69.95% Cl.1.06-2.70;P-0.03).There was no significant differencein the rates of severe adverse events

between groups.

Conclusion:Mycophenolate moletil was less effective than A 2A lor maintaining disease remission in AAV.

WGEI

IMPROVE JAMA 2010;304:2381-88

MEJM 2010:363:221-32 Title: Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis

Purpose:To investigate if rituximab is more effective and/or safer than a cyclophosphamide for treating AAV.

Methods:197 ANCA-positive patients randomly assigned to receive rituximab (375 mg/m1for 4 wk) or cyclophosphamide (2 mg/kg/d).

Results:64% of Ihe rituximab group reached the primary endpoint (remission of disease without the use olprednisone at 6 mo),as

compared with53% of controls (nonInferiority.P<0.001). Rituximab was moreeffective than cyclophosphamide for inducing remission

of relapsing disease;67% vs.42% reached the primary endpoint (P-0.01).

Conclusion:In severe AAV.rituximab wasnoninferior to cyclophosphamide for remission inductionand may be superior in relapsing

disease.

Title: long-term Rituximab Use to MaintainRemission olAntmcutrophil Cytoplasmic Antibody Associated Vasculitis:A RandomizedInal

Purpose:To assess Ihe efficacy ol prolonged rituximab therapy in reducing AAV relapses in patients in complete remission following an

initial phase of maintenance therapy.

Methods:68 patients were randomized to receive an infusion ofrituximab or placebo every 6 mo for 18 mo.

Results:At 28 mo. estimates of relapse- free survival were 96% and 74% in the rituximab and placebo groups,respectively,

representing an absolute difference of 22% (Cl. 9 -36%) and a hazard ratio of 7.5 (Cl.1.67- 33.7)|P'0.003).

Conclusion:Prolonged rituximab therapy resulted in lower ratesof AAV relapse than standard maintenance therapy.

RAVE

MAINRITSAN3 Ann Intern Med

2020:173:179-187

GOUT

Febuxostat Compared with

Altopurinol in Patients with

Hyperuricemia andGout . Becker

etal.2005

HEJM 2005;353:2450 - 61 Title:Febuxostat Compared with Altopurinol inPatients with Hyperuricemia and Gout

Purpose:loinvestigate the use of febuxostat as a potential alternative to altopurinol foi patients wilh hyperuricemia and gout.

Methods: 762 patients with gout and with serum urate:8.0mg/dl were randomly assigned to receive either daily febuxostat (80 or 120

mg) or daily altopurinol (300 mg) for 52 wk.

Results:Primary endpoint (serum urate <6.0 mg/dlat the last 3 monthly measurements) occurred in 53% of patients on febuxostat 80

mg. 62% on febuxostat 120 mg.and 21% on altopurinol (P- 0.001for both febuxostat groups vs.altopurinol).The overall incidence of

gout flares during wk 9-52 was similar in all groups and decreased withcontinued treatment.

Conclusion:In patients withhyperuricemia and gout,febuxostat was more effective than altopurinol at towering serum urate.

ANKYLOSING SPONDYLITIS

ATLAS Arthritis Rheum

2006:54:2136 46

Title: Efficacy and Safety of Adalimumab in Patients with Ankylosing Spondylitis:Results of a Multicenter,Randomized,Double-Blind,

Placebo-Controlled Trial

Purpose: loassess the safety and efficacy ol adalimumab in patients with active AS.

Methods:208 AS patients were randomly assigned lo SC injection of adalimumab (40 mg every other wk) or placebo loi 24 wk.Primary

outcome was a 20% response according to the Assessment in AS International Working Group (ASA20).

Results:58.2% of adalimumab-treated patients reached an ASAS20 response at wk12 vs.20.6% of placebo-treated patients

(P«0.001).Adalimumab alsodemonstrated significantly greater ASAS40 and ASAS5/6 responses at wk 12 and 24 (P'

0.001).Significantly

more adverse events were seen wilhadalimumab.

Conclusion:Adalimumab was well-tolerated andclinically effective in treating active AS.

Title:Efficacy and Safety of Infliximabin Patients withAnkylosing Spondylitis:Results of a Randomized.Placebo-Controlled Trial

(ASSERT)

Purpose:lo evaluate the efficacy and safety of infliximab inAS.

Methods:279 patients were randomly assigned lo receive 5 mg/kg infliximab infusions at wk 0.2.6.12. and 18. or placebo.Primary

outcome was a 20% response according to the Assessment in AS International Working Group (ASA20).

Results:As compared withplacebo,significantly more patients on infliximab achieved the primary outcome (61.2% vs.19.2%)

IP'

0.001).Infliximab produced clinical benefits beginning at wk 2 that were sustained over the 24 wk. Adverse events were common in

both groups but generally mid-moderate in severity.

Conclusion:In patients with AS.infliximab was clinically effective and well tolerated over 24 wk.

Title: Efficacy of Etanercept on Rheumatic Signs and Pulmonary Function Tests in Advanced Ankylosing Spondylitis:Results of a

Randomized Double-BlindPlacebo-Controlled Study (SPINE)

Purpose:To assess the efficacy of etanercept (ETN) in advanced AS.

Methods:82 patients wilh severe, active AS that were refractory lo NSAIOs and anti-INF naive were treated wilhETN 50 mg once per

wk or placebo.

Results:Over 12 wk.there were significantly greater improvements in the Bath AS Oisease Activity Index IBASDAI)in the E1H group

vs.placebo group (-19.8:16.5 vs.-11.0:16.4.P'0.019).ETH also improved CRP levels (P'

0.001).total back pain (P'0.010),and FVC

(P-0.006).

Conclusion:In advanced AS.ETN has short-term efficacy for improving pain. CRP. spinal mobility and pulmonary function.

Title: Sulfasalazine in the Treatment of Spondylaithropathy.A Randomized.Multicenter,Double-Blind. Placebo Controlled Study

Purpose:To evaluate the safety and efficacy of SS2 in treating spondylarthropathy.

Methods:351patients with active disease despite treatment with NSAIOs receivedSS2 (3 g/d) or placebo.Primary efficacy outcomes

included the patient

's and physician's overall assessments,pain,and morning stiffness.

Results: 60% olpatients taking SS2 improved by at least1/5 points on patient assessmenl of disease activity,in conlias!to 44%

taking placebo (only significant difference among 4 primary outcomes).SS2 had greater clinical efficacy in a subgroup of patients with

psoriatic arthritis,as measured by primary efficacy variables and joint inflammation.

Conclusion:SS2 was more effective than placebo in treating active spondylarthropathy.particularly in patients withpsoriatic arthritis.

ASSERT Arthritis Rheum

2005:52:582-91

SPINE Ann Rheum Dis

2011:70:799 -804

p t

L J

Sulfasalazine Arthritis Rheum

1995:38:618 27

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RH35Rheumatology Toronto Xotes 2023

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Saadoun D.Terrier B,Semoon 0.et alHepatitis C virus-associatedpolyartenbs nodosa.Arthritis Care Res (Hoboken) 2011:63:427-435.

Shiboski CH.Shiboski SC.Seror R.et al.2016 ACR-EULAR classification criteria for primary Sjogren's syndrome:Aconsensus and data-driven methodology involrng three international patient cohorts.Arthntis

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Shojania K.What laboratory tests are needed? CMAJ 2000:162:1157-1163.

Sieper J.Rudwaleit M. BaraliakosJletal.The assessment of SpondyloArthntsInternationalSociety (ASAS) handboofcAguide to assess spondyloarlhritis.Aim Rheum Dis 2009;68:1-44.

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RH36 Rheumatology Toronto Notes 2023

SmghJASaagKG.Bridges SLJr.et si.2015 American College of Rheumatology guideline for the treatment of rtieurnatoid arthritis.ArthritisRheum 2018:68:1-26.

Srrera F.Andres M.Carmona Let aL Recommendation:Multinational evidence-based recommendations lor the diagnosis andmanagements gout:integrating systematic literature review and eipert opinion of

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Urology

Adree Khondker and Shamir Malik, chapter editors

Chunyi Christie Tan and Vrati Mehra, associate editors

Arjan S. Dhoot, HBM editor

Dr. Monica Barcas, Dr. Yonah Krakowsky, Dr. Jason Lee, and Dr. Michael Ordon,staff editors

..U2 Selected Urological Procedures

.. Bladder Catheterization

Circumcision

,U4 Vasectomy

U4

Cystoscopy

Radical Prostatectomy

Transurethral Resection of the Prostate

Extracorporeal Shock Wave Lithotripsy

U6 Transition-Related Surgeries

Common Medications

Acronyms U43

Basic Anatomy Review

Urologic History

Hematuria

Macroscopic (Gross) Hematuria

Microscopic Hematuria

Lower Urinary Tract Dysfunction

Urinary Incontinence

Lower Urinary Tract Symptoms.

Urinary Retention

Benign Prostatic Hyperplasia

Urethral Stricture

Neurogenic Bladder

Dysuria

Hydronephrosis

Post-Obstructive Diuresis

Overactive Bladder

Infectious andInflammatory Diseases.

Urinary Tract Infection

Recurrent/Chronic Cystitis

Interstitial Cystitis (Painful Bladder or Bladder Pain Syndrome)

Acute Pyelonephritis

Prostatitis/Prostatodynia

Epididymitis and Orchitis

Urethritis

Stone Disease

Approach to RenalStones

Urological Neoplasms

Approach to Renal Mass

Benign Renal Neoplasms

Malignant Renal Neoplasms

Carcinoma of the Renal Pelvis and Ureter

Bladder Carcinoma

Prostate Cancer

PSA Screening

Testicular Tumours

Penile Tumours

Scrotal Masses

Penile Complaints

Erectile Dysfunction

Trauma

Renal Trauma

Bladder Trauma

Urethral Injuries

Infertility and Andrology

Female Factors

Male Factors

Testosterone Deficiency

Paediatric Urology.

Congenital Abnormalities

Wilms’Tumour (Nephroblastoma).

Cryptorchidism/Ectopic Testes

Disorders of Sexual Differentiation

Enuresis

Bladder and Bowel Dysfunction

U47

^ Landmark Urology Trials.. ,U48

References. ,U49

U12

U13

U18

U21

U32

,U33

,U35

U37

U39

,U39

U42

+

Ul Urology Toronto Xotcs 2023

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Acronyms

ADT androgen deprivation therapy EPS

AFP alpha-fetoprotein

assisted reproductive

technologies

ASA acetylsalicylic acid

AUA American Urological Association

BBD bladder and bowel dysfunction HPF

BCG Bacillus Calmette-Guerin

BPH benign prostatichyperplasia

BPKVP bipolar plasma kinetic

vaporization of the prostate

CAH congenital adrenalhyperplasia 11-2

CaP cancer of the prostate

continuous bladder irrigation

cystic fibrosis

CFU colony-forming unit

CHF congestive heart failure

clean intermittent

catheterization

PCa prostate cancer

PCKD polycystic kidney disease

PCNl percutaneous nephrolithotomy SWl

POE phosphodiesterase

PFMT pelvic muscle floor training

PGE1 prostaglandin E1

PID pelvic inflammatory disease

i pelvic lymph node dissection

PMC pontine micturition centre

post-obstructive diuresis

PSA prostate specific antigen

PUV posterior urethral valve

peripheral vascular disease

PVP photoselective vaporization

of the prostate (GreenLight

Laser)

PVR post-void residual

QOL quality of life

RCC renal cell carcinoma

randomized controlled trial

radio-frequency ablation

radical prostatectomy

RPLNO retroperitoneal lymph node

dissection

RR respiratory rate

RTA renal tubular acidosis

RUG retrograde urethrogram

SA semen analysis

SCC squamous cell carcinoma

SEEK PP Staphylococcus saprophyticus.

E.coli.Enterococcus. Klebsiella. WHO

Proteus.Pseudomonas

SFU Society of Fetal Urology

SLN sentinel lymph node

SUI stress urinary incontinence

(extracorporeal) shockwave

lithotripsy

TNM tumour node metastasis

TMP.’SMX trimethoprim/sulfamethoxazole

TRUS transrectal ultrasound

TUIP transurethral incision of the

prostate

transurethral microwave therapy

transurethral resection of

bladder tumour

TURP transurethral resection of the

prostate

U/0 urine output

urothelial carcinoma

UMN upper motor neuron

UPJ ureteropelvic junction

URS ureterorenoscopy

UTD urinary tract dilation

urinary tract infection

ureterovesical junction

V81 voided bladder,initial (urethra)

VB2 voided bladder,midstream

(bladder)

VB3 voided bladder,post-massage/

digital rectal exam

VCUG voiding cystourethrogram

visual internal urethrotomy

VUR vesicoureteral reflux

World Health Organization

expressed prostatic secretions

fine needle aspiration

general anesthesia

glycosaminoglycan

high-intensity focused

ultrasound

high power field

hypothalamic-pituitary-testicular PLND

FNA

ART GA

GAG

HIFU

HPTA

a - .

ICSI intracytoplasmic sperm injection POD

IFN-a interferon-alpha

interleukin-2

IPSS InternationalProstate Symptom PVD

Score

ISD intrinsic sphincter deficiency

intrauterine insemination

IVF in vitro fertilization

intravenous pyelogram

KUB kidneys,ureters,bladder

LFT liver function test

LMN lower motor neuron

LUTS lower urinary tract symptoms RP

MET medical expulsive therapy

MS multiple sclerosis

motor vehicle collisions

NMIBC non-muscle invasive bladder

TUMT

TURBT

CBI

CF

IUI uc

ac IVP

OS carcinoma in situ

CMG cystometrogram

CRPC castrate-resistant prostate

cancer

CTU CT urography

CUA Canadian Urological Association MVC

CVA costovertebral angle

d/c discharge

DHT dihydrotestosterone

DMSA dimercaptosuccinic acid

digital rectal exam

RCT

RFA UTI

UVJ

cancer

NSGCT non-seminomatous germ cell

tumour

OAB overactive bladder

detrusor sphincter dyssynergia OPORSTUonset.position,quality,

external beam radiation therapy

erectile dysfunction

VIU

DRE

DSD

EBRT radiation,severity,temporality,

ED deja vu

Basic Anatomy Review

• recall that the anatomical position of the penis is erect:therefore, the anatomical ventral side of the penis appears to be the dorsal side of the

flaccid penis

s - Above -

arcuate line

Superficial fascia

External oblique

Internal oblique

Transvcrsus abdominis

Transversals fascia

Extrapentoneal fat

Peritoneum

vlI

.

'

to ,

Testicular *

artery

> Vas External

spermatic fascia

Cremaster

, muscle

Internal

i

]

spermatic fascia

[t— Tunica vaginalis

Oartos fascia

Deferens A

Pampiniform

plexus

Below arcuate line /*

_ Infenor epigastric artery

-Skin

-Superficial fascia

-External oblique

-Internal oblique

-Transvcrsus abdominis x

- Transversals fascia

-

Extrapentoneal fat

-

Pentoncum

j

t Testis I

-

&

Skin V2 v

V

Figure1. Midline cross-section of abdominal wall Figure 2. Anatomy of scrotum

-Renal cortex

.Renal medu!a

Minor calyx JMajor calyx —V

Renal sious —y

Renal pe'

vts —*

Renal vein T3

Renal artery

(Leal pap. a

anal column

Anal pyramid

rfienol capsule

IGerota'

s fascial Abdominal aorta

Inferior vena cava

Ureter

Gonadal artery and vem

Internal iliac artery and vein

External iliac artery and vem

Internal pudcnal artery

Common penile artery

Detrusor

Trigone

Base detrusor

Urethral muscular s (internal

sphincter,smooth muscle)

Periurethral striated muscle

Rhabdosphincterl«MHnal

sphincter,striated musclel

icular junction

ri

Membranewurethra -

Posterior urethra

Bulbar urethra

L j

i

i

r

-

k—A

s. nterior urethra

c

~

n

2

L Spongy (penile) urethra

_ Corpus cavemosum

L Corpus spongiosum

t Meatus

=

© ©

cn +

Figure 3.Essential male genitourinary tract anatomy

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U3 Urology Toronto Note

*

2023

Superficial dorsal vein

Deep dorsal vein

Dorsal artery

Dorsal nerve

Corpus cavernosum

Deep artery

Urethra

Corpus spongiosum

Transverse Sections of Penis Skin

Loose areolar tissue

Deep fascia

Tunica albuginea

Superficial

'

dorsal vein

.Deep

dorsal vein

I Skin

Gians penis

Dorsal vein

Dorsal artery

Dorsal nerve

/

-Dorsal artery

Corpus cavernosum

Corpus spongiosum

Urethra c

:

2

Distal (foreskin retractedl

Figure 4. Cross section of the penis

Ductus deferens

! Seminal vesicle

Ampulla of

/ ductus deferens

Pubic symphsis

Prostate

Urethra Rectum

Bulbourethral gland

Ductus

i t

:

f - i

£

2

S—

Figure 5. Median sagittal section of the male pelvis and perineum

Sympathetic IT10-L2) ON Parasympathetic (S2-S4) OFF

Sympathetic (T10-L2)

•Hypogastric nerve

•NE adrenergic receptors

• Iroceptor internal urethral

sphincter contraction

• 3 receptor -> detrusor relaxation

Pelvic nerve >

<

Somatic (S2-S4)

•Pudendal nerve

•ACh nicotinic receptors external

Hypogastric nerve urethral sphincter contraction Internal urethral sphincter

2

Parasympathetic (S2-S4) Off s

I

a

Somatic IS2-S4) ON

I Pudendal nerve External urethral sphincter

-

-

M

u

Figure 6. Bladder innervation during storage phase

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Ul Urology Toronto Notes 2023

Sympathetic (T10-L2) OFF Parasympathetic {S2-S4) ON

Sympathetic (T10-L2) Olf

•Internal urethral sphincter relaxation

Pelvic nerve ltrCACh >

j>

33 Somatic (S2-S4) Off

•External urethral sphincter relaxation <

N E

>|

Parasympathetic (S2-S4)

•Pelvic nerve

•ACh -> muscarinic receptors

detrusor contraction

Hypogastric nerve

Internal urethral sphincter

—cx

Somatic (S2-S4) OFF

I Pudendal nerve

£

External urethralsphincter s

a

Figure 7. Bladder innervation during voiding phase

Urologic History

• follow OPQRST'

U approach

• note that pain may not be limited to the genital region (e.g. lower abdomen,CVA)

• urinary habits

• LUT S (see Lower Urinary Tract Symptoms, U7)

• storage symptoms:frequency, urgency (rush to toilet), nocturia (1

;

UN )

• voiding symptoms:stream changes/straining, hesitancy, incomplete emptying, post-void

dribbling (SHED)

• dvsuria: burning, pain on voiding

• hematuria: blood clots, red/pink tinged urine (see Hematuria)

• incontinence:stress, urgency, mixed,overflow (see Urinary Incontinence, U6)

• sexual function

scrotal mass (see Scrotal Masses,U32)

» ED (see Erectile Dysfunction, U33)

• female sexual dysfunction (dvspareunia, low desire, arousal disorder, orgasmic dysfunction)

• infertility (see Infertility, U37 )

• associated symptoms

• N/ V

• bowel dysfunction

• constitutionalsymptoms

• fever, chills, unintentional weight loss, night sweats, fatigue,malaise, bone pain

• risk factors: past urologic disease (e.g. UTI,stones,ST1, cancers, anatomic abnormalities), EMHx,

medications, lifestyle factors (e.g.smoking, alcohol, inactivity), trauma, previoussurgical procedures

Always ask aboutsexual function on

history.Change in erectile function can

be one of the first symptomsthat there

is concomitant vascular disease. If there

is new onset ED. consider screening for

DM and CAD risk factors

Hematuria

Macroscopic (Gross) Hematuria

Definition

• blood in the urine that can he seen with the naked eye

Classification

• see Nephrology

Gross, painless hematuria in adults is

bladder cancer until proven otherwise

Etiology

Table 1. Etiology by Age Group

Age (yr) Etiology

0 20 UII. glomerulonephritis, congenital abnormalities

UII.stones, bladder tumour,exercise

Male: bladder tumour,stones. UII. prostate cancer

Male: 8PH. bladder tumour , UII, RCC, prostate cancer

20- 40

40 60 female: UII. stones, bladder tumour +

»

60 female: bladder tumour , UII. RCC

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U5 Urology Toronto Notes 2023

Table 2. Etiology by Type

Pseudohematuria Infectious/ Inflammatory Malignancy Benign Structural Hematologic

Pyelonephritis

Cystitis

Urethritis

RCC (mainly adults)

Urothelial cancer

Wilms' tumour (mainly

paediatric)

Prostate cancer

Leukemia

Stones

Trauma

Foreign body

Urethral stricture

Polycystic kidneys

Arteriovenous malformation

Infarct

Hydronephrosis

Fistula

Vaginal bleeding

Dyes (beets,rhodamine B in

candy and juices)

Hemoglobin (hemolytic anemia) Glomerulonephritis

Myoglobin (rhabdomyolysis) Interstitial nephritis

Drugs (rifampin,

phenazopyridine,phenytoin)

Porphyria

Laxatives (phenolphlhalcin)

BPH Anticoagulants

Coagulation defects

Sickle cell disease

Thromboembolism

Polyps

Exercise-induced

Tuberculosis

History

• timing ofhematuria in urinary stream

beginning of micturition: anterior urethra

end of micturition: bladder neck, prostatic urethra

• entire duration of micturition: bladder and above

• presence of blood clots

• LUTS and associated symptoms

• pyuria, dvsuria, urgency: UTT

flank pain, radiation:ureteral obstruction

• last menstrual period, history of kidney stones, UTT,or previous urologic surgery

recent UTT, post-infectious glomerulonephritis, IgA nephropathy

• medications (anticoagulants, rifampin, phenazopyridine, phenytoin)

• risk factors for malignancy (smoking, chemical exposures, Hx of cyclophosphamide therapy, pelvic

radiation)

Common Uiologic Causes of Hematuria

can be Classified as:

TICS

Trauma/Tumour/Toxins

Infection/Inflammatory

Calculi/Cysts

Surgery/Sickle cell and other

hematological causes

Upper Tract Imaging Options

• CT Urography (CTU):Test of choice

to evaluate the renal parenchyma

and collecting system. Involves

exposure to radiation and IV contrast

(assess renal function and allergies)

• U/S:Superior to IVP for evaluation of

renal parenchyma and renal cysts:

limited sensitivity for Urothelial

carcinoma and small renal masses:

U/S alone may be insufficient for

upper tract imaging

• Magnetic Resonance (MR)

Urography:Evaluation of renal

parenchyma, collecting system and

congenital anomalies: beneficial in

paediatric or pregnant patients or

when ionizing radiation has to be

avoided,(assess renal function and

allergies)

Investigations

• U/A, urine C&S, urine cytology

• imaging

lower tract: cystoscopy

upper tract:CT Urogram (gold standard), U/S

• CBC (rule out anemia,leukocytosis), electrolytes,creatinine (Cr), blood urea nitrogen (BUN),1NR,

partial thromboplastin time (PI T), PSA (in men)

Acute Management of Severe Bladder Hemorrhage

• manual irrigation via catheter with normal saline to remove clots

• CB1 using large ( 20-2-1 l-

'