Semen Values

• Volume:1.5-7.6 mL

• Concentration:>15 million sperm/mL

• Morphology:30% normal forms

• Motility:>40% adequate forward

progression

• Liquefaction:complete in 20 min

. pH:7.2-78

. WBC: <10/HPF or <106 WBC/mL

semen

History

• age of both partners

• medical: past illness, DM, trauma,CF, genetic syndromes,STls,cryptorchidism

• surgical:vasectomy, herniorrhaphy, orchidopexy, prostate surgery

• fertility: pubertal onset, previous pregnancies, duration of infertility, treatments

• sexual:libido, erection/ejaculation, timing,frequency

. FMHx

• medications:cytotoxic agents, GnRH agonists, anabolic steroids, nitrofurantoin, cimetidine,

sulfasalazine,spironolactone, a-blockers

• social Hx:alcohol, tobacco, cocaine, cannabis,school performance/learning disabilities (suggestive of

Klinefeltersyndrome)

• occupational exposures: radiation,heavy metals

Physical Exam

• general appearance:sexual development,gynecomastia, obesity, pubic hair

• scrotal exam:size,consistency, and nodularity of testicles; palpation of cord for presence of vas

deferens; DRE; valsalva for varicocele

Hypo-gonadal patients Interested in

fertility preservation should be cautioned

against the isolated use of exogenous

testosterone and be counseled to

pursue treatments that increase

endogenous serum testosterone

production

ri

+

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Investigations

• SA £2 specimens, collected I -2 wk apart

• hormonal evaluation

indicated with abnormal SA (rare to be abnormal with normal SA)

testosterone and l-

'

SH

serum LH and prolactin are measured if testosterone or TSH are abnormal

• genetic evaluation

chromosomal studies (Klinefelter syndrome - XXY)

genetic studies (Y-chromosome microdeletion, CP gene mutation)

• immunologic studies (antisperm antibodies in ejaculate and blood)

• testicular biopsy

• scrotal U/S (varicocele, testicular size)

• vasography (assess patency of vas deferens)

SFU Grading of Hydronephrosis

Grade 0

• No dilation, calyceal walls are

opposed to each other

• Grade1(mild)

• Dilation of renal pelvis without

dilation of the calyces

• No parenchymal atrophy

Grade 2 (mild)

• Dilation of renal pelvis and calyces

(pclvicalyccal pattern Is retained)

• No parenchymal atrophy

Grade 3 (moderate)

• Moderate dilation of renal pelvis and

calyces

• Mild calyceal thinning, blunting of

fornices. and flattening of papillae

Grade 4 (severe)

• Gross dilation of renal pelvis and

calyces with loss of borders

• Cortical thinning

Treatment

• assessment of partner

• lifestyle

• regular exercise, healthy diet

eliminate alcohol, tobacco, and illicit drugs

• medical

endocrine therapy (see Endocrinology, E51)

• treat retrograde ejaculation

• discontinue anti-sympathomimetic agents, may start a-adrcnergic stimulation

(phenylpropanolamine, pseudoephedrine, or ephedrine)

treat underlying infections

• surgical

varicocelectomy (if indicated)

vasovasostomy (vasectomy reversal) or epididvmovasostomy

transurethral resection of blocked ejaculatory ducts

• assisted reproductive technologies (ART)

refer to infertility specialist

sperm washing + intrauterine insemination (1U1)

in vitro fertilization (1VF)

• intracytoplasmic sperm injection ( 1CSI) after Cl- screening of patient and partner in patients with

congenital bilateral absence of vas deferens

Note:SFU grading should be

supplemented with UTD grading to

address the shortcomings of this grading

system.

o

Hydroureter:

o

f

Semen Analysis ) Azoospermia J

Bilateral testicular

atrophy

Normal or unilateral

testicular atrophy Absent/low volume ejaculate,

positive lor sperm

Serum FSH [ Serum FSH ]

Hydroureter:

r/o short abstinence period,

incomplete collection

Low High Abnormal

I I o

I

Hypogonadotropic Primary testicular

hypogonadism failure ^

Post-ejaculatory urinalysis )

Normal

±

Testicular biopsy j

fve for sperm ve for sperm Abnormal

!

( Retrograde ejaculation ] ( Transreclal U/S

J

Normal Hydrometer:

Abnormal anatomy Normal anatomy [ Obstruction

V

O

Determine level ol

obstruction

Failure ol emission

Figure 21. Infertility workup

Hole:aroospermic pabenIs with normal FSH may be assumed to be obstrucbve without a testicular biopsy

Hydrometer:

r T

i j

+

Hydroureter:

Figure 22. SFU grading (based on

ultrasound)

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U39 Urology Toronto Notes 2023

Testosterone Deficiency

See Endocrinology.ESI

Clinical Features

• sexual:decreased libido,delayed ejaculation, reduced ejaculate volume, decreased orgasm intensity,

erectile dysfunction, loss of morning erections, infertility

• cognitive:fatigue, mood changes, depression, insomnia, irritability

• physical:decreased energy, anemia, gynecomastia, hot flushes, decreased muscle mass and increased

visceral body fat,osteopenia, testicular atrophy,loss of androgenic hair

Diagnosis

• clinical features ± total testosterone (morning draw) < 10 nmol/L

• LH to rule out causes ofsecondary hypogonadism

Treatment Considerations

• see Endocrinology.E51

• goal: improve quality of life and reduce clinical features while achieving eugonadal testosterone

• if clinical features with normal testosterone

• rule out depression,hypothyroidism,sleep disorders

• consider measuring sex-hormone binding globulin and determinine free/total testosterone ratio

• supervised trial of testosterone therapy for three mo (injectable, oral, transdermal patch)

• iflow testosterone without clinical features

• Consider other diagnoses: anemia,sarcopenia, chronic glucocorticoid/opioid use, HIV

• no role for testosterone therapy

• in all patients treated with exogenous testosterone: monitorsymptoms, adverse events,serum

testosterone, hematocrit, and PSA at 3, 6, and 12 mo, then qlyr, DRE recommended at baseline and

qlyr

Paediatric Urology

Congenital Abnormalities

• not uncommon; 1 in 200 have congenital abnormalities of the GU tract

• six common presentations of congenital urological abnormalities

1. ANTENATAL HYDRONEPHROSIS

Epidemiology

• l-5% fetal U/S,some detectable as early as first trimester

• most common urological consultation in perinatal period and one of most common U/S abnormalities

of pregnancy

Differential Diagnosis

• transient primary hydronephrosis

• UP) obstruction

• VUR

• U VJ obstruction or primary non-obstructive megaureter

• ureterocele

• ectopic ureter

• causes of megacystitis (e.g. PUV, Prune Belly syndrome)

Treatment

• antenatal in utero intervention rarely indicated unless evidence of lower urinary tract obstruction

with oligohydramnios

• ABx prophylaxis at birth to reduce UT1 ratesis controversial but may be beneficial to infants with

high grade hydronephrosis, dilated ureter, or bladder abnormality.Commonly used ABx include:

amoxicillin, cephalexin, and trimethoprim

S

i

:

•

t

Figure 23. VUR grading

(based on cystogram)

VUR

e

Grading (based on cystogram)

Grade I:ureters only fill

Grade II:ureters and pelvisfill

Grade III: ureters and pelvisfill with

some dilatation

Grade IV:ureters, pelvis,and calycesfill

with significant dilatation

Grade V: ureters, pelvis,and calycesfill

with major dilatation and tortuosity

n

L J

2. POSTERIOR URETHRAL VALVES

Epidemiology

• the most common congenital obstructive urethral lesion in male infants +

Defer circumcision in patients with

hypospadias

Pathophysiology

• abnormal mucosal folds at the distal prostatic urethra causing varying degrees of obstruction

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Clinical Features

• dependent on age

antenatal:bilateral hydronephrosis,distended bladder, oligohydramnios

neonatal (recognized at birth): palpable abdominal mass (distended bladder, hydronephrosis),

urinary ascites (transudation of retroperitoneal urine), respiratory distress (pulmonary

hypoplasia from oligohydramnios), weak urinary stream

neonatal (not recognized at birth):within daysto weeks present with urosepsis, dehydration,

electrolyte abnormalities,failure to thrive;rule out pyloric stenosis, which may present similarly

toddlers: UTls or voiding dysfunction

school

-aged boys: voiding dysfunction -> urinary incontinence

• associated findings include renal dysplasia and secondary VUR

Investigations

• most commonly recognized on prenatal U/S -> bilateral hydronephrosis, thickened bladder, dilated

posterior urethra (“keyhole sign”), oligohydramnios in a male fetus

• VCUG -> dilated and elongated posterior urethra, trabeculated bladder, VUR

Treatment

• immediate catheterization to relieve obstruction, followed by cystoscopic resection of PUV when baby

isstable

• if resection of PUV is not possible, vesicostomy is indicated

3. URETEROPELVIC JUNCTION OBSTRUCTION AntlmkrobidlProphylaxis lot Children with

VesicoureteralReflux

NEJM 2014:370:2367-2376

Purpose:lodetermine whether long-term

antimicrobial prophylaxis is tlfectnt in preventing

recurrences of till and reducing the hkelhood of

renal scarring.

Methods:Children with vesicoureteral leHuxthat

were diagnosed after a hirst orsecond febrileor

symptomatic till were randomized to either receive

Irimethopriia-sulfametliOMiOle prophylaxis or

placebo.

Results:Prophylaxis reduced the risk ol recurrences

try 50% and was particularly effective in children

whose index infectim wasfebrile and in those

with baseline bladder and bowel dysfunction.Ihe

otcuirence olrenalscarring dd notdiffeisignificantly

between the two groups.

Conclusions lit b otic proph ytans given to chddren

with vesicoureteral reflux after a UII resulted in a

reduction of subsequent tills, but was not associated

with reduced risk ol renalscarriag.

Etiology

• unclear: adynamic ureteralsegment,stenosis,strictures, extrinsic compression, aberrant blood

vessels

• can rarely be secondary to tumour,stone, etc. in children

Epidemiology

• the most common congenital defect of the ureter

• M:l

'»2:l

• up to 40% bilateral, which may be associated with svorse prognosis

Clinical Features

• symptoms depend on severity and age at diagnosis (mostly asymptomatic finding on antenatal U/S)

• infants: abdominal mass, urinary infection

• children:pain, vomiting

• some cases are diagnosed after puberty and into adulthood

in adolescents and adults, the symptoms may be triggered by episodes of increased diuresis,such

as following alcohol ingestion (Dietl'

s crisis)

, failure to thrive

Investigations

• antenatal:serial U/S most common, and renalscan with furosemide

Treatment

• surgical correction (pycloplasty), consider nephrectomy if <15% differential renal function Glanular*

Coronal*

Subcoronal

4. VESICOURETERAL REFLUX •

-Distal Penile -

I

Definition

• retrograde passage of urine from the bladder, through the U V J,into the ureter

Classification

• primary reflux:incompetent or inadequate closure of UV)

lateral ureteral insertion,short submucosal segment

• secondary reflux: abnormally high intravesical pressure resulting in failure of U V) closure

often associated with anatomic (FUV) or functional (neuropathic) bladder dysfunction

Midshalt

Proximal Penile

nuscrutal

Epidemiology

• estimated -1% of newborns,but not well known

• incidence and clinical relevance higher in children with febrile UTls and prenatal hydronephrosis

• risk factors: race (white > black),female gender, age (<2 yr), genetic predisposition

[]

Investigations

• focused Hx, particularly of voiding dysfunction (frequency, urgency, diurnal enuresis, constipation,

encopresis)

also screen for infections(UTI, pyelonephritis, urosepsis) and renal failure (uremia, HTN)

+

Figure 24. Classification of

hypospadias ('account for 75%)

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•initial evaluation of renal status, growth parameters, and blood pressure is warranted in any child

with V UR due to relatively high incidence of renalscarring

height, weight, blood pressure

serum Cr

U/A.C&S

renal U/S

DMSA renal scan if at high-risk (greater sensitivity in detecting structural defects associated with

dysplasia,renalscarring,or pyelonephritis; entails radiation exposure)

sibling family screening is controversial

•Diagnose VUR and determine grade with VCUG

Treatment

•spontaneous resolution in 60% of primary reflux

• in lower grades (l-lll), goal is to prevent infection or renal damage via medical treatment

•medical treatment: daily ABx prophylaxis at half the treatment dose for acute infection (see Table 8,

Uli

- TMP/SMX, trimethoprim, amoxicillin, or nitrofurantoin)

•surgical treatment: ureteral reimplantation ± ureternplasty, orsuhureteric injection with bulking

agents (Deflux* or Macroplastique*)

• indications include failure of medical management, renal scarring (e.g. renal insufficiency, HTN ),

breakthrough Uils, persistent high grade (IV or V ) reflux

5. HYPOSPADIAS

Definition

•a condition in which the urethral meatus opens on the ventral side of the penis, proximal to the

normal location in the glans penis

•depending on severity, may result in difficulty directing urinary stream, having intercourse, or

depositing sperm in vagina

Epidemiology

t very common; I in 300 live male births

•distal hypospadias more common than proximal

•white»black

•may be associated with ventral penile curvature,disorders of sexual differentiation, undescended

testicles,or inguinal hernia

Treatment

•early surgical correction; optimal repair before 2 yr

•neonatal circumcision should be deferred because the foreskin may be utilized in the correction

6. EXSTROPHY-EPISPADIAS COMPLEX

Definition

•a spectrum of defects depending on the timing of the rupture of the cloacal membrane

bladder exstrophy:congenital defect of a portion of lower abdominal and anterior bladder wall,

with exposure of the bladder lumen

cloacal exstrophy

exposed bladder and bowel with imperforate anus

associated with spina bifida in >50%

epispadias (leastsevere)

urethra opens on dorsal aspect of the penis,often associated with penile curvature

Etiology

•representsfailure of closure of the cloacal membrane,resulting in the bladder and urethra opening

directly through the abdominal wall

Epidemiology

•rare:incidence 1 in 30000, M:F=3:1 predominance

•high morbidity -> multiple reconstructive surgeries, incontinence, infertility, reflux

Treatment

•surgical correction at birth

•later correctionsfor incontinence,VUR,and low bladder capacity may be needed

n

u I

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Wilms’Tumour (Nephroblastoma)

Etiology

• arises from abnormal proliferation of metanephric blastema

Epidemiology

• 5-10:5% of all childhood cancers,5% bilateral,10% associated with congenital malformation

syndromes

• most common primary malignant renal tumour of childhood

• average age of incidence is 3 yr

Clinical Features

• abdominal mass:large,firm, unilateral (80%)

• HTN (25%)

• flank tenderness(30-40%)

• microscopic hematuria (12-25%)

• nausea/vomiting

Associated Syndromes of Wilms’

Tumour

• Wilms' aniridia genital anomaly

retardation

• Beckwith-Wiedemann syndrome

• Dcnys-Drash syndrome Treatment

• always investigate contralateral kidney and renal vein (for tumour thrombus)

unilateral disease:radical nephrectomy or nephron-sparing surgery ± radiation ± chemotherapy

• bilateral disease: nephron-sparing surgery following neoadjuvant chemotherapy

Prognosis

• Syr survival 80%

Cryptorchidism/Ectopic Testes

Definition

• abnormal location of testes somewhere along the normal path of descent (external inguinal ring >

inguinal canal > abdominal)

• Denis Browne pouch (between external oblique fascia and Scarpa’sfascia) most common

• differential diagnosis:

retractile testes

atrophic testes

disorders ofsexual differentiation (bilateral impalpable gonads)

Normal Testicular Development and

Descent in Utero

• 2nd mo: Testide beginsto form

• 4th mo:Begins to take on its normal

appearance and migratesfrom its

origin at the kidney to the internal

inguinal ring

. 7th mo: The testis,surrounded

In peritoneal covering, begins to

descend through the internal ring,

inguinal canal, and external ring to

terminate in the scrotum

Epidemiology

• 1.0-4.6% of full term newborns, increased risk in preterms

. 0.7-1.0% at I yr

Treatment

• orchiopexy

• hormonal therapy not proven to be of benefit overstandard surgical treatment

Prognosis

• reduction in fertility

untreated bilateral cryptorchidism:

-100% infertility, due to Leydig and germ cell loss

• paternity rates: 33-65%,90%, and 93% in formerly bilateral cryptorchid,formerly unilateral

cryptorchid,and normal men,respectively

• increased malignancy risk

intra-abdominal > inguinal

surgical correction facilitates testicular monitoring and may reduce malignancy risk

• increased risk of testicular torsion (reduced by surgical correction)

Disorders of Sexual Differentiation

Definition

formerly known asintersex disorders:considered social emergency

• abnormal genitalia for chromosomal sex due to the undermasculinization of males or the virilization

of females

Classification

1.46 XY DSD

• defect in testicularsynthesis of androgens

androgen resistance in target tissues

• palpable gonad

2.46 XX DSD

• most due to GVH (21-hydroxylase deficiency most common enzymatic defect) -> shunt in steroid

biosynthetic pathway leading to excess androgens

A phenotypic male newborn with

bilateral non-palpable testiclesshould

be considered 46 XX with salt-wasting

CAH and must undergo proper

evaluation prior lo discharge

+

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undiagnosed and untreated CAH can be associated with life-threatening electrolyte

abnormalities in the newborn (salt-wasting CAH)

3. ovotesticular DSD

4. mixed gonadal dysgenesis (46 XY/45 XO most common karyotype)

» presence of Y chromosome -> partial testis determination to varying degrees

Diagnosis

•thorough T'

MHx noting any consanguinity

•maternal Hx, especially medication /drug use during pregnancy (maternal hyperandrogenemia)

•P/E: palpable gonad (

= chromosomal male), hyperpigmentation, evidence of dehydration, HTN,

stretched phallus length, position of urethral meatus

•laboratory tests

• plasma 17-OH-progesterone (after 36 h oflife) -> increased in CAH

• plasma 11-deoxycortisol > increased in 1 1-(1-hydroxylase deficiency

basal adrenal steroid levels

serum testosterone and DHT pre- and post-hCG stimulation (2000 lU/d for 4 d)

• serum electrolytes

chromosomal evaluation including sex karyotype

•U/Sof adrenals,gonads, uterus, and fallopian tubes

•endoscopy and genitography of urogenital sinus

Treatment

•steroid supplementation asindicated (e.g.CAH)

•sex assignment after extensive family consultation

must consider capacity for sexually functioning genitalia in adulthood,fertility potential, and

psychological impact

•reconstruction of external genitalia between 6and 12 mo

•long-term psychological guidance and support for both patient and family

Enuresis

. see Paediatrics. PI1

Bladder and Bowel Dysfunction

Definition

• bladder and bowel dysfunction describes voiding and defecation symptoms without a neurogenic or

anatomic cause

Clinical Features

• storage symptoms (urgency,frequency, urge incontinence)

• voiding symptoms (hesitancy,slow (low, intermiltency)

• gastrointestinal symptoms(constipation and encopresis)

Treatment

• stool softeners (i.e. polyethylene glycol 3350)

• urotherapy and bladder retraining

• pelvic floor physiotherapy

• anticholinergics (solifcnacin, propiverine, tolterodine)

• neuromodulation via transcutaneous electrical nerve stimulation

Selected Urological Procedures

Bladder Catheterization

•catheter size measured by the Trench (T’

r) scale - circumference in mm (30 T'

r = 1 cm diameter)

•each 1 mm increase in diameter = approximately 3 Tr increase (standard size 14-18 T'

r)

•should be removed assoon as possible to reduce the risk of UT1

Continuous Catheterization

•indications

accurate monitoring of U/O

relief of urinary'retention due to medication, neurogenic bladder, or intravesical obstruction

temporary therapy for urinary incontinence

perineal wounds

clot prevention (22-24 Tr) for CB1

intra- and postoperative

comfort for end oflife care

n

LJ

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Alternatives to Continuous Catheterization

• intermittent catheterization

PVR measurement

to obtain sterile diagnostic specimens for VI A, urine C&S

management of neurogenic bladder or chronic urinary retention

• condom catheter

• suprapubic catheter

Robinson tip

Coude tip

Inflation port Causes of Difficult Catheterizations and Treatment

• patient discomfort > use sufficient lubrication (± xylocaine)

• collapsing catheter > lubrication as above ± firmer or larger catheter (silastic catheter)

• meatal/urethral stricture > dilate with progressively larger catheters/ balloon catheter

• traumatic injury: repeated prior attempts at catheterization have created traumatic false passage

• BPH > use Coude catheter as angled tip can help navigate around enlarged prostate (always angle up/

anteriorly)

• urethral disruption/obstruction > filiform and followers orsuprapubic catheterization

• anxious patient -> anxiolytic medication

i

( « Urine

Two-way Foloy

Inflation port

( • Urine

Complications of Catheterization

• infection: UT1, bladder fistula, bladder perforation (rare)

• meatal/urethral trauma

C 1

^Irrigation port

Three-way Foley I

Figure 25.Transurethral (Foley)

catheters

Contraindications

• trauma: hlood at the urinary meatus,scrotal hematoma, pelvic fracture, and/or high riding prostate

Circumcision

Newborn MaleCifCumcision

Patdulr Child H«IM 2015:20311-315

Study: Position Staterr e~ tby ttieCanadion Paediatric

Society (CPS|reaffirmed Feb 28, 2018

Recommendations: Vitbthe eiception of some

higb-risk populations end circumstances where

circumcision isindicated for disease prevention,

reduction ani

'or treatment,the routine circumcision

of every newborn maleisnotretommended.

Definition

• removal ofsome or all of the foreskin from the penis

Epidemiology

• 30% worldwide

• frequency varies with geography, religious affiliation,socioeconomic status

Medical Indications

• pathological phimosis and recurrent paraphimosis

• recurrent UT Is (particularly in infants and in association with other urinary abnormalities)

• balanitis xerotica obliterans or other chronic inflammatory conditions

Mile Circumcision tor Prevention of Heterosexual

Acquisition of HIV in Mea

Cochrane OB Syst Rev 2009:2:C0003362

Purpose: to evi’uite the effectivenessind solely ol

male circumcision (or presenting acquisition ol HIV m

heterosexual men.

Methods: Iheaiiiyied data sfrom three rar dom red

controlled trialstoassessthe efficacy ol male

circumcision for prerertng HIV acquisition in men

in Africa.

Results: Medical nsalerircumcisiDo reducesthe

acquisition of HIV by heieraseoal men|38-6G% over

24mo).

Contraindications

• unstable or sick infant

• congenital genital abnormalities (hypospadias, epispadias, penoscrotal webbing, concealed penis,

ventral curvature);may need foreskin to aid in reconstruction

• FMHx of bleeding disorders warrants investigation prior to circumcision

Complications

• early: bleeding, infection, glans injury, amputation,slippage of circumcision device, rarely death

• late: redundant foreskin, cosmetic issues, inclusion cysts, adhesions/skin bridges, suture sinus tracts,

ventral curvature,secondary buried penis, phimosis, fistula, meatal stenosis

• 0.6-2% complication rate laparoscopic aud Robotk-Assistrd vi.Open

Radical Prostatectomy 1«the Irealmeril ol

localised ProstateCancer

Cochrane 08Syst Rev 2017;9:CD009625

Purpose: to compare the effects of laparoscopic

radical prostatectomy (IRP) and robotk-assisted

radical prostatectomy (RIRP)to the retropubic open

radical prostatectomy (ORP) in men with local sed

prostate cancer.

Methods:the review identified two unique RCTs

with direct companion of IIPar.d RARP to ORP i n

446 patients.

Results: MtencomparedtoORP. umary and seiual

quality ot life related outtomesappeaisimilailoilRP

and RARP. Men who underyjIRP and RARP may have

snorter hospital stay (M0.22.96% Cl 2.19 to -1.25)

and icquire Iewer 9 cod tiansfusons|RR 0.24. 95%0:

0.12 0.46). the ntra- and postoperative complication

rates appear similar.

Conclusions: Jtfo.qh there is no high-qua! ty

evidence to compare LRP and RARP to ORP m terms ol

oncological outcomes,patients undergoing IRPor RARP

may receive fewer hlood transfusions and have shorter

hospitalstays,the interventions did not difter in terms

nt urziary a nd seiual quality of life-related outcomes

and serious postoperative complication rates.

Vasectomy

Objective

• permanent form of contraception with high probability of reversibility

• no-scalpel vasectomy haslower risks of early postoperative complications than conventional

vasectomy

• fascial interposition and cautery of the vas deferens reduce risk of contraceptive failure

• post-vasectomy semen analyses at approximately 3 and 4 mo

• other contraceptive methods should be used post-vasectomv until one azoospermic ejaculate or two

consecutive ejaculates with <100000 immotile spermatozoa

Indications

• fully informed patient desiring permanent surgical sterilization

Complications

• early: infection (0.2-1.5%), bleeding or hematoma (4-20%), primary surgical failure due to

recanalization or technical failure (0.2-5%)

• late: chronic scrotal pain (1-14%), delayed vasectomy failure (0.05-1%)

• risk of pregnancy after vasectomy is ~0.1%

+

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Post-vasectomy follow-up

• I (or 2) semen analyses at 3(or 4) months post-vasectomy

• Abandon contraception:if azoospermic or <100 000 immotile sperm at any time post-vasectomv

• Re-do vasectomy: if >100 000 immotile sperm or motile sperm on repeatsemen analysis 4-8weeks

after initial

Cystoscopy

Objective

• endoscopic inspection of the lower urinary tract (urethra, prostate, bladder, and ureteral orifices),

samples for cytology

• scopes can be flexible or rigid

• done under local anesthesia only for vast majority,with no special preparation needed (no NPO, no

antibiotics)

Indications

• hematuria

• LUTS (storage or voiding)

• urethral and bladder neck strictures

• bladderstones

• bladder tumoursurveillance

• evaluation of upper tracts with retrograde pyelography (ureteric stents,catheters)

Complications

• during procedure (very rare)

bleeding

anesthetic-related

perforation (rare)

• post-procedure (short-term)

infections (antibiotic prophylaxis recommended only for high-risk, immunosuppressed)

* urinary retention

• post-procedure (long-term)

stricture

Radical Prostatectomy

Objective

• the removal of the entire prostate and prostatic capsule via a lower midline abdominal incision,

laparoscopically, or robotically

open surgery'is extraperitoneal, minimally-invasive surgery is usually intraperitoneal approach

internal iliac and obturator lymph nodes may also be dissected and sent for pathology (dependent

on risk:clinical stage, grade, PSA)

seminal vesicles are also partially or completely removed

Indications

• treatment for localized prostate cancer

sometimes done concurrently with radical cystectomy forlocally advanced bladder cancer

Complications

• immediate (intraoperative)

blood loss

rectal injury (extremely rare)

• ureteral injury (extremely rare)

obturator nerve injury (extremely rare)

• perioperative

lymphocele formation (if concurrent pelvic lymphadenectomy performed)

blood loss

urine leak from anastomosis

• late

moderate to severe stress urinary incontinence (3-10%)

mild stress urinary incontinence (20-30%)

ED (

-30-50%, depending on whether one, both, or neither of the neurovascular bundles are

involved in extracapsular extension of tumour)

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U46 Urology Toronto Notes 2023

Transurethral Resection of the Prostate

Objective

• to partially resect the periurethral portion of the prostate (transition zone) to decrease symptoms of

urinary tract obstruction

• accomplished via a transurethral (cvstoscopic) approach using an electrocautery loop, irrigation

(glycine),and illumination

• not a cancer operation

standard TURF done with electrocautery;newer surgical optionsfor BPH include green-light

laser photovaporization, bipolar ablation,water-vapour therapy (Rezume)

Indications

• obstructive uropathy (large bladder diverticula,renal insufficiency)

• refractory urinary retention

• recurrent UTIs

• recurrent gross hematuria

• bladder stones

• intolerance/failure of medical therapy

Complications

• acute

intra- or extraperitoneal rupture of the bladder

rectal perforation

incontinence

incision of the ureteral orifice (with subsequent reflux or ureteral stricture)

hemorrhage

• epididymitis

sepsis

transurethral resection syndrome (also called “post-TURP syndrome”)

caused by absorption of a large volume of the hypotonic irrigation solution used, usually

through perforated venoussinusoids,leading to a hypervolemic hyponatremic state

characterized by dilutional hyponatremia, confusion, nausea, vomiting, HTN, bradycardia,

visual disturbances,CHF,and pulmonary7

edema

treat with diuresis and (ifsevere) hypertonic saline administration

• chronic

retrograde ejaculation (>75%)

ED (5-10% risk increases with increasing use of cautery)

incontinence (<1%)

• urethralstricture

bladder neck contracture

Extracorporeal Shock Wave Lithotripsy

Objective

• to treat renal and ureteral calculi (proximal, middle,or distal) which cannot pass through the urinary

tract naturally

usually performed undersedation only- no internal instrumentation required;least invasive

treatment option but also leastsuccessful

• shockwaves focused onto stone -> fragmentation, allowing stone fragmentsto passspontaneously and

less painfully

Indications

• potential first-line therapy for renal <1.5 cm and ureteral calculi

• individuals with calculi in solitary kidney (consider stenting kidney to prevent obstruction)

• patient preference and wait-times play a large role in stone management

performed under fluoroscopic-guidance,so stone needs to be radio-opaque (i.e. NOT for uric acid

stones)

Contraindications

• acute UT1 or urosepsis

• bleeding disorder or coagulopathy

• pregnancy

• uncontrolled HTN

• obstruction distal to stone (SU L can be used after stent or nephrostomy inserted)

not a contraindication but SWL lesssuccessful for very dense stones and in obese patients

n

t

- J

Complications

• bacteriuria

• bacteremia

• post-procedure hematuria (common to have mild gross hematuria)

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• ureteric obstruction (by stone fragments)

• peri-nephric hematoma

Transition-Related Surgeries

• ensure appropriate use of gender pronouns

• some procedures require I yr trial of hormone therapy, preoperative letters of evaluation and

documentation from mental health professionals as outlined by the World Professional Association

for Transgender Health Standards of Care - Version 7 guidelines

Table 26. Surgical Options for Gender Transition (Also known as Gender Affirmation Surgery)

Procedure Description Follow- Up

Scrotal incision and removal ol bilateral testicles

Scioteelomy in some patients

Ordiioctomy Eliminates need lor testosterone blockers

Allows lor luck with great case

Penile Inversion Vaginoplasty Formation ol vaginal cavily and vulva (clitoris, urethra , mens, labia) using lubrication required lor penelration

penile and scrotal skin Prostate crams conducted vaginally

Regular dilation ol vaginal cavity lo avoid stenosis

Complications:granulation tissue, urinary symptoms, listula formation.

hair growth in neovagina

Radial Forearm Phalloplasty

Most common technique lor phallic

reconstruction

loimation ol penis using radial loreaim gralt ol skin, blood vessels and

nerves

Urethral extension

lulure penile and testicular implants

loimation ol penis using skin, blood vessels, ncives and muscular tissue High complication rate as above

Itom thigh

Urethral extension

luturepenile and testicular implants

Formation of a penisthrough release ol hormonally-enlarged clitorisfrom tower complication rates when compared to phalloplasty

suirounding ligaments

Girth added fiom neighbouring tissue

-

urethroplasty

t vaginectomy and scrotoplasty

High complication rates related to urethral connection (urethral listula.

stricture, post void dribblingTstream spraying, urinary retention ), skin

complications and implant issues

Anterolateral Thigh (All) Phalloplasty

Pedicle flap failure very rare

Phallus maybe very thick due to subcutaneouslal ol thigh

Sensory recovery may be pooler than radial arm llap

Metoidioplasty

Hot capable of penetrative intercourse Major complications mayrequire

revision

surgery:urethral strictures, urethral fistulas

Common Medications

Table 27. Erectile Dysfunction Medications

Drug Class Mechanism Adverse Effects

sildenafil

tadalafil

vardenafil [PDESsfor use when some

erection present)

Severe hypotensbn (very rare)

Flushing,headaches,dyspepsia

leads to sinusoidalsmooth muscle relaxation,increased Contraindicated it Hi ol priapism,or in conditions

predisposing lo priapism (leukemia,myelofibrosis,

polycythemia,sickle cell disease)

Contraindicated with nitrates

Penile pain

Presyncope

thickening ol tunica albuginea atsite ol repeated

injections (Peyronie'

s plague)

Painful erection

Hematoma

Contraindicated if Hi ol priapism,or in high -risk ol

priapism

Phosphodiesterase 5 inhibitor Selective inhibition of P0E5

(enzymewhich degradescGMP)

blood (low and erection

alprostadil (MUSE = ).PGfc

-

phentolamine

-

papaverine mixture

alprostadil. papaverine

(intracavernosal injection)

Prostaglandin El Activation of cAMP, relaxing sinusoidal smooth muscle

focal release (urethral suppository)

See above See above

triple therapy also used:

papaverine, phentolamine.

PGEt

Table 28. Benign Prostatic Hyperplasia Medications

Drug Class Mechanism Adverse Effects

terazosin

doxazosin

a adrenergic antagonists reduce stromal smooth muscle Prcsyncopc

leg edema

Reduce dynamic component of bladder outlet obstruction Retrograde ejaculalion

Headache

Asthenia

Nasal congestion

al blockers

lone

lamsulosin

allutosin

sllodosin

finasteride

dulasteridc

ou selective

Sexual dysfunction

Reducesstatic component ol bladder outlet obstruction PSA decreases

Reduces prostatic volume

S o reductase inhibitor Blochs conversion ol testosterone lo DHI

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Table 29. Prostatic Carcinoma Medications (N>0, M>0)

Drug Class Mechanism Adverse Effects

GnRH agonist Initially stimulates LH.increasing testosterone and

causing “flare*(initially increases bone pain)

Later causes low testosterone

Competitively binds to the pituitary gland GnRH

receptors,thereby reducing the release of LH.FSH and

consequently testosteroneby testes

Hot flashes

Headache

Decreased libido

Back pain

Breast enlargement

Decreased libido

Hot flashes

Headache

Slow or fast heartbeat

leuprolide.goserelin

“androgendeprivation therapy"

degarelii GnRH antagonist

Steroidal antiandrogen Competes with DH1for intracellular receptors:

Prevent flare produced by GnRH agonist

Use forcompleteandrogen blockade

May preserve potency

As above

Irreversible cytochrome P450 (CYP) 17 inhibition,

blocking synthesis of androgens in tumour,testis,and

adrenal glands

'cyproteroneacetate

Hepatotoxic:AST/ALI monitoring

Adrenal insufficiency (concurrent treatment with steroids

often required)

Hypertriglyceridemia

Peripheral edema

Peripheral edema

Fatigue and weakness

Hot flashes

flutamide,bicalutamide

abiraterone

Non-steroidal antiandrogen

Non-steroidal antiandrogen

enralutamide Non-steroidal antiandrogen Androgen receptor signaling inhibitor (full antagonist)

’Very rarely used

Table 30. Continence Agents and Overactive Bladder Medications

Drug Class Mechanism Indication Adverse Effects

Antispasmodic Inhibits action olacetylcholine on smooth

muscle

Decreases frequency of uninhibiteddetrusor

contraction

Diminishes initial urge to void

^

-sympathetic receptor blocker in the

bladder:relaxes bladder during storage

phase

Overactive bladder

Urge incontinence -^ urgency » frequency

Dry mouth

Blurred vision

Constipation

Supraventricular tachycardia

oxybutynin

Anticholinergic Overactive bladder

Urge incontinence *

urgency » frequency

oxybutynin As above

lolterodine

Irospium

solifenacin

darifenacin

fesoterodine

propiverine

mirabegron j)lagonist Sympathomimetic effects:

Urinary sphincter contraction

Anticholinergic effects:

Detrusor relaxation

Prevents the release of neurolransmitlcrs

Overactive bladder

Urge incontinence ^urgency » frequency

Blood pressure should be monitored

imipramine Tricyclic antidepressant Stress and urge incontinence As above

Weight gain

Orthostatic hypotension

Prolonged PR interval

Prevents the release of neurotransmillcrs Refractory OAB incontinence both Urinary retention.UII

neurogenic andnon- neurogcnic

Botulinum toxin A bladder

injections

Neurotoxin

Note:Allanticholinergics aie equally effective andlong-acting formulations are better tolerated. Newer muscarinic M3 receptor specific agents (solifenacin,darllenacin) are equally efficacious as older

drugs, however,RCTs based on head-to-head compalison to long acting formulations ale lacking

Landmark Urology Trials

Trial Name Reference Clinical Trial Details

BENIGN PROSTATIC HYPERPLASIA

PCP1 N Engl J Mud 2003:349:215 -224 Title: The Influence of Finasteride on theDevelopment of Prostate Cancer

Purpose: lo determine whether the drugFinasteride|5-alpha reductase inhibitor) could prevent prostale cancer in men ages

55 and older.

Methods:18882 men 55 yr or older with a normal digitalrectal examination and a (PSA) level equal lo or less than 3.0 ng per

milliliter were randomly to receive finasteride (5 mg per day) or placebo for 7 yr.

Results: There was a 24.8% reduction inprostate cancer prevalence over the 7-yr periodamong the Finasteride arm compared

lo the placebo arm (95 % confidence interval, 18.6 lo 30.6 percent;P'

0,001).However there was a significant increase in highgrade disease among men in the finasteride group compared to the placebo (6.4 % vs. 5.1% P'0.005).

Conclusion: the PCPf trial in 2003 was the first study to show that a medication (Finasteride) reduces the likelihood ol

developing prostale cancer.Upon long term follow-up in 2013,this reduction in risk has been attributed to less likelihood ol

low-grade cancers in men taking finasteride.Although participants who developed prostate cancer while taking finasteride

were motelikely to have high- grade cancers,this increase was attributed to better detection of disease rather than

medication use. +

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Trial Name Reference Clinical Trial Details

Title:The Long-Term Effect ol Doxazosin,Finasteride,and Combination Therapy on the ClinicalProgression of Benign Prostalic

Hyperplasia

Purpose:To determine whether therapy with doxacosin (a blocker) or finasteride(So-reductase inhibitor),alone or in

combination, would delay or prevent clinical progression of benign prostatic hyperplasia (BPH).

Methods:Participants were followed- up for a mean lime of 4.5 yr to compare the effects of the interventions. The primary

outcome was overall clinical progression of BPH ( >4points Irom baseline in ADA symptoms score,acute urinary retention,

urinary incontinence,renal insufficiency,or recurrent UTI).

Results: The risk oloverall clinical progression was significantly reduced by doxazosin (39% lisk reduction.P- 0.001) and

linastcride (34% risk reduction.P‘0.002), as compared with placebo,and the risk was reduced even more with combination

therapy (66%lor the comparison with placebo.P‘

0.001) compared with doxazosin (P'

0.001) or finasteride (P‘

0.001) alone.

Conclusions: Long-term combination therapy with doxazosin and finasteride reduced the clinical progression of BPH

sigmlicantly more than each therapy alone,as well as reduce the need for invasive therapy in the long term.

MTOPS HJLM 2003:349:2387-2398

BLADOER CARCINOMA

Heoadjuvanl Chemotherapy

plus Cystectomy Compared with

Cystectomy Alone for locally

Advanced Bladder Cancer

NEJM 2003:349:859 866 Title: Heoadjuvanl Chemotherapy plus Cystectomy Compared with Cystectomy Alone for locally Advanced Bladder Cancer

Purpose: To evaluate whether the addition of neoadjuvant chemotherapy to radical cystectomy improves oulcomcsin

patients with locally advanced bladder cancer.

Methods: 317 patients with transitional-cell carcinoma of Ihe bladder (T 2N0M0 to IdaNOMO) were randomized to undergo

radical cystectomy or to receive three cycles of combined chemotherapy followed by radical cystedomy.

Results: At 5 yr after treatment initiation,57% of the combination- therapy group vs. 43% of Ihe cystectomy group were alive

(P‘0.06).In the combinalion-lhcrapy group.38% of Ihe patients werepathologically lice of cancer at the timeof cystectomy

vs.15% of the cystectomy -only group at Ihe lime of surgery (P‘

0.001).