Saturday, August 30, 2014

Analysis of Robot-Assisted Versus Laparoscopic Live Donor Nephrectomy

Efficacy and Safety of Local Steroids for Urethra Strictures

Urologic Problems in Spina Bifida Patients Transitioning to Adult Care

Approaches to Pediatric and Adolescent Varicocele

MCRPC Featured Articles

Individualized Decision-Making for Older Men With Prostate Cancer: Balancing Cancer Control With Treatment Consequences Across the Clinical Spectrum

Abiraterone acetate for treatment of metastatic castration-resistant prostate cancer: fi nal overall survival analysis of the COU-AA-301 randomised, double-blind, placebo-controlled phase 3 study

A Wealth of New Options: A Case Presentation of the Management of Castration-Recurrent Prostate Cancer

ORIGINAL ARTICLE Interleukin 6 downregulates p53 expression and activity by stimulating ribosome biogenesis: a new pathway connecting inflammation to cancer

Chronic inflammation is an established risk factor for the onset of cancer, and the inflammatory cytokine IL-6 has a role in tumorigenesis by enhancing proliferation and hindering apoptosis. As factors stimulating proliferation also downregulate p53 expression by enhancing ribosome biogenesis, we hypothesized that IL-6 may cause similar changes in inflamed tissues, thus activating a mechanism that favors neoplastic transformation. Here, we showed that IL-6 downregulated the expression and activity of p53 in transformed and untransformed human cell lines. This was the consequence of IL-6-dependent stimulation of c-MYC mRNA translation, which was responsible for the upregulation of rRNA transcription. The enhanced rRNA transcription stimulated the MDM2-mediated proteasomal degradation of p53, by reducing the availability of ribosome proteins for MDM2 binding. The p53 downregulation induced the acquisition of cellular phenotypic changes characteristic of epithelial–mesenchymal transition, such as a reduced level of E-cadherin expression, increased cell invasiveness and a decreased response to cytotoxic stresses. We found that these changes also occurred in colon epithelial cells of patients with ulcerative colitis, a very representative example of chronic inflammation at high risk for tumor development. Histochemical and immunohistochemical analysis of colon biopsy samples showed an upregulation of ribosome biogenesis, a reduced expression of p53, together with a focal reduction or absence of E-cadherin expression in chronic colitis in comparison with normal mucosa samples. These changes disappeared after treatment with anti-inflammatory drugs. Taken together, the present results highlight a new mechanism that may link chronic inflammation to cancer, based on p53 downregulation, which is activated by the enhancement of rRNA transcription upon IL-6 exposure.

Friday, August 29, 2014

This CT was performed 2 days after resection of a bladder tumour. What does it show?

It shows extravasation of urine with a significant leak from the bladder extending posteriorly and intra-peritoneally

This is a CT scan with contrast in a middle-aged man with gross haematuria. Cystoscopy had shown no abnormality in the bladder. What does the CT show?

The left kidney is normal. Contrast medium in the right kidney outlines a large, irregular filling defect in the renal pelvis. Cytology showed malignant transitional cells and ureterorenoscopy confirmed a papillary, transitional cell tumour of the renal pelvis which was removed by nephroureterectomy (see macroscopic pathology below).

This is a CT scan with contrast in a patient who presented with pain in the back & left loin and was found to have microscopic haematuria on routine urine testing. What does the CT show?

There is good contrast uptake in the right kidney. In the left kidney, uptake is poor and the aorta has a double lumen. These are the appearances of acute aortic dissection with relative ischaemia of the left kidney.

What is this investigation & what does it show?

This is a bilateral vasogram, performed under general anaesthetic, in an azoospermic patient. It shows normal vasa but the seminal vesicles are distended due to congenital obstruction of the ejaculatory ducts. The absence of seminal fluid fructose is characteristic of this condition because fructose is produced only in the seminal vesicles. Endoscopic incision of the ducts usually results in restoration of fertility. After such treatment, this patient fathered two children and, later, requested vasectomy.
There is now a move away from surgery in most men with obstructive azoospermia towards testicular/epididymal sperm aspiration & assisted conception.

This is a CT scan through the pelvis. What is the abnormality seen and what is its significance?

This shows a superfical bladder tumour on the left with a jet of contrast medium issuing from the ureteric orifice. This implies that the ureter is not obstructed and, therefore, that the bladder tumour is non-invasive. Primary ureteric tumours, even if non-invasive, can obstruct the lumen of the ureter

This is a plain abdominal X-ray in a 40-year-old woman with haematuria and recurrent urinary infections. She had an intra-uterine contraceptive fitted 10 years earlier but, despite that, had become pregnant. What does the X-ray show?

There is an opacity in the pelvis consistent with a bladder calculus. The appearance of the stone, however, is unusual. When it was crushed & removed, a Dalkon shield IUCD was found at its centre and had clearly been inserted into the urethra, not the cervix, 10 years earlier

This is an ultrasound scan of the urethra, performed during voiding, in a man with post-micturition dribbling. What abnormality is shown?

This shows an abnormal cavity ventral to the urethra which represents an anterior urethral diverticulum. The diverticulum is best seen on voiding and may be missed on a retrograde contrast study

What abnormality is shown on this abdominal CT scan?

This is a large, right renal tumour with nodal involvement. The inferior vena cava is not well seen. At histological analysis, the tumour had penetrated the renal capsule, involved lymph nodes and showed microvascular invasion; these are all adverse prognostic features. The IVC was not involved but simply compressed by tumour bulk

CT scan was performed in an elderly man admitted as an emergency with pyrexia, retention of urine and severe pelvic pain. What abnormality is shown?

There is gross disorganisation of the anatomy of the prostate. The lumen of an urethral catheter can be seen in the centre of the prostate and the bladder is just visible anteriorly. This is an acute prostatic abscess associated with acute bacterial prostatitis.

This is an IVU in a child who presented with urinary infection and left loin pain. What does the X-ray show and how is this condition best managed?

The IVU shows missing calyces at the top of the left kidney and a mass in the bladder. The remaining calyces on the left have the appearance of a 'drooping flower'. These findings are typical of an ectopic ureterocele with a non-functioning upper moiety and a large ureterocele in the bladder where the ectopic ureter opens.The lower moiety ureter seen on the IVU is displaced laterally by the dilated ectopic ureter which contains urine but no contrast medium.Treatment is by partial nephroureterectomy to remove the upper moiety & ureter together with either complete excision of the ureterocele from the bladder or simple endoscopic incision. The latter is often preferred because excision may compromise the other (normal) ureter which often then requires reimplantation.

This is the plain abdominal X-ray of a lady who had accidentally introduced a foreign body into her bladder. What is the foreign body and why had the patient inserted it into her bladder?

This is a clinical thermometer.She had been advised by a fertility clinic to monitor her temperature on a daily basis (to assess ovulation) and was unaware that a simple oral temperature would suffice.

What investigation is being performed here?

This is an antegrade pyelogram, performed as part of an antegrade pressure-flow study (Whitaker test) to determine the presence of obstruction in the ureter. The pressure difference between renal pelvis & bladder is measured during perfusion of fluid at a constant rate (10 ml/min) through the collecting system. A rise in pressure (>15 cm of water) is suggestive of obstruction. The increasing senstivity of renography means that the Whitaker test is now rarely performed.

This is a bone scintigram in an elderly man with back pain and obstructive lower urinary tract symptoms. What does the scintigram show and what is the most likely cause of the abnormalities?

There are multiple areas of abnormal isotope uptake throughout the skeleton consistent with widespread bony metastases. The right kidney is obstructed and dilated.
The most likely cause is disseminated carcinoma of the prostate with distant spread to the axial skeleton and local spread into the bladder base resulting in ureteric obstruction with a poorly-functioning right kidney. The patient's PSA was >1000 ng/ml which confirms the diagnosis

What abnormality is seen in this ultrasound scan of a testis?

This is testicular microcalcification. Its significance is uncertain but it may be associated with carcinoma-in-situ and it should be followed up by regular (annual) ultrasound in men less than 50. It is seen in congenitally abnormal testes, in infertile men and following trauma or surgery but its significance in older men is not clear

What abnormality is shown here in the plain abdominal X-ray of a lady who underwent hysterectomy and then developed recurrent bladder infections with left loin pain?

There are surgical clips on the left side of the pelvis. There isgas in the bladder and a gas pyelogram with air visible in the ureter and in the collecting system of the left kidney (visible behind the stomach gas). These findings are the result of fistulation of the left ureter into the bowel, probably as a result of damage to both during the gynaecological surgery. Treatment is by reimplantation of the ureter and repair of the bowel; at operation, a fistula was found into a loop of small bowel in the pelvis

Wednesday, August 27, 2014

 treatment of neurogenic bladder

 prevention of ileus and intestinal atony following surgery

postoperative urinary retention

Distigmine Bromide (Distigmine bromide 5mg tablets)

Ubretid (discontinued in the UK - February 2013)

Monday, August 25, 2014

32nd World Congress Meeting on Endourology

As the Congress Organizer, it gives us great pleasure to welcome you to the 32nd World Congress of Endourology and SWL (WCE 2014) to be held in Taipei, Taiwan from September 3-7, 2014. WCE is without a doubt the largest and most important event for endourologists worldwide. Our team will continue the tradition and exert great efforts to ensure the impending WCE vent a fabulous one, both in terms of the scientific programs and social activities.

Sunday, August 24, 2014

Schrier's Diseases of the Kidney, 9th Edition.pdf

Saturday, August 23, 2014

SIU 2014 Glasgow, Scotland Register by August 29 and Save!

In a few weeks, Glasgow will welcome thousands of urologists to one of the world’s premier urology congresses. Don’t miss your last chance to save on the registration fees. 

Friday, August 22, 2014

Benign Prostatic Hyperplasia _BPH_ Treatment ...

MCQ Urology

Department of Urology, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ

Sunday, August 17, 2014

Male Urinary Organ Anatomy • Author: Patrick Joseph Fox Jr, MD; Chief Editor: Thomas R Gest, PhD


An understanding of the anatomy of the male urinary organs, namely the male urethra and penis, is crucial to the diagnosis and treatment of urologic conditions. While it is true that the longer male urethra confers some protection against urinary tract infections, it can also pose other problems more common to men than women, including strictures and stenosis. This article provides some basic anatomy of the urinary organs specific to the male. There is also a brief discussion of anatomical variations and the complications arising therein. The anatomy of the kidneys, ureters, and bladder are similar for males and females. See image below.
Male  urinary organs, anterior view.

Gross Anatomy


The penis is the external genital organ of the male. The spongy or penile urethra travels through the penis and opens at the urethral meatus of the glans penis. The urethra is contained within the corpus spongiosum, one of three corpora, or erectile bodies of the penis.[1] The paired corpora cavernosa comprise the other two. Each corpora is contained within a fibrous tissue layer called the tunica albuginea.[2] More superficially, deep penile (Buck) fascia encircles the three corpora, and then with superficial perineal (Colles) fascia, an extension of the membranous layer of superficial fascia (Scarpa fascia) of the abdominal wall.[2]The penis is contained within a layer of epidermis.[2] See the images below.

Corporal bodies of the penis.

Cross-sectional  anatomy of the penis.

Tunica coverage of the penis.


The urethra is the tubular structure that carries urine from the bladder to the exterior. It is considerably longer in males than in females, with a length of approximately 17-20 cm and 2.5-4 cm, respectively.[1] The male urethra has 3 sections, including the prostatic urethra, the membranous urethra and the penile, or penile (spongy) urethra.
The prostatic urethra is the most proximal section of urethra exiting the bladder and is so named as it is surrounded by the prostate gland.[3]
Distal to the prostatic urethra, the membranous urethra begins at the lower end of the prostate and extends to the perineal membrane. This section is encompassed by the external urethral sphincter.[2, 3]
Finally, the penile, or spongy, urethra runs through the corpus spongiosum of the penis and is the longest portion of the male urethra. The penile urethra begins at the perineal membrane and continues to the urethral meatus. Just proximal to the meatus, the penile urethra contains the fossa navicularis, a widened portion of the urethra located in the glans.[2] The penile urethra can be further subdivided into the bulbar and pendulous urethra. The bulbar urethra is the more proximal portion of the penile urethra at the widened proximal end (or bulb) of the corpus spongiosum as it makes the curve from the pelvic floor to the join the corpus cavernosa. Once the three cavernous bodies have joined, the more distal portion of the penile urethra is termed the pendulous urethra.
Additionally, the urethra is divided into both anterior and posterior segments.[2] The anterior segment includes the urethral meatus to the bulbar penile urethra. The membranous and prostatic urethra are considered elements of the posterior segment. See the image below.

Divisions of the urethra.

The internal urethral sphincter, located at the junction of the urethra and the bladder, is made up of smooth muscle fibers from the bladder’s detrusor muscle and is involuntarily controlled.[1] The external urethral sphincter is made up of the skeletal muscle comprising the pelvic floor and is under voluntary control.
Branches of the internal pudendal arteries serve the penis and urethra.[2] These branches include the deep penile arteries, a dorsal artery of the penis, and the artery of the bulb.[2] The deep penile arteries supply the corpora cavernosa, while the dorsal artery and artery of the bulb supply the glans, urethra, and corpus spongiosum.[2] See the image below.
Arterial supply to the penis

Venous return is via the deep dorsal vein, which lies beneath the deep penile (Buck) fascia between the dorsal arteries of the penis.[2] The superficial dorsal vein, located outside of the deep penile fascia, drains to the femoral vein via the superficial external pudendal vein, while the deep dorsal vein drains into the prostatic plexus, which in turn drains to the internal pudendal vein.[2] See the image below.
Venous drainage of the penis.

Microscopic Anatomy

The corpora are made up of smooth muscle septae around vascular cavities.[2] The urethral mucosa is made up of both squamous epithelium as well as transitional epithelium. As the urethra transverses the glans penis, it is lined with squamous, and more proximally, by transitional epithelium.[2] The submucosa of the urethra contains connective tissue, elastic tissue as well as smooth muscle.[2]
As mentioned above, the internal urinary sphincter is made up of smooth muscle cells from the detrusor muscle of the bladder. Conversely, the external urethral sphincter is made up of voluntarily controlled skeletal or striated muscles.

Natural Variants

Overall, the length of the male urethra may vary from person to person and depends on numerous factors. The penile urethra has the most variation in length compared with the other segments. Congenitally short penis is termedmicrophallus.

Pathophysiological Variants

Many variants of the male urinary organs are diagnosed and corrected in childhood.
Meatal stenosis is a narrowing of the urethral meatus as it opens on the glans penis. The stenosis is most often thought to be caused by friction and inflammation following circumcision, leading to scarring of the meatus.[2]
Another anomaly, urethral stricture can be either congenital or acquired. Congenital strictures of the urethra, while uncommon, occur most often in the fossa navicularis or membranous urethra.[2] Acquired strictures of the urethra are more common than congenital ones and most often result from pelvic or perineal trauma or infection. Straddle injuries can cause bulbar urethral strictures, whilepelvic fractures and trauma can lead to disruption of the membranous urethra, leading to strictures.[2] The collagenous tissue that forms the stricture, either congenital or acquired, causes outflow obstruction.[2] This obstruction may lead to damage of the kidneys and bladder if not corrected.
Posterior urethral valves are the most common obstructive urethral lesions in children and infants.[2] They are found at the distal prostatic urethra and are formed by mucosal folds resembling membranes and can obstruct urine outflow, causing damage to the kidneys.
Hypospadias is a condition in which the urethral meatus opens on the ventral aspect of the penis. There are varying types of hypospadias, with type 1 being a glandular hypospadias where the orifice opens on the glans, but more proximal than the orthotopic meatus.[2] Type 2 occurs when the meatus opens on the coronal sulcus of the glans. Type 3 involves the shaft of the penis.[2] Type 4 is a penoscrotal opening, and type 5 is a perineal opening.[2] Approximately 70% of hypospadias cases are of type 1 or 2.[2] Epispadias, conversely, is a meatus opening on the dorsal aspect of the penis and is much less common than hypospadias.
These are just a few of the numerous urethral anomalies that can lead to problems with urination, as well as damage to the bladder and kidneys.

Other Considerations

As men age, the prostate gland, located just distal to the bladder, and surrounding a portion of the urethra, can continue to grow, or hypertrophy, leading to a condition known as benign prostatic hypertrophy. As men age, there is a proliferation of epithelial and stromal cells in the periurethral area of the prostate.[4]As the prostate grows, it can compress the urethra as it passes through the prostate, thus causing signs of obstruction, as mentioned above.

1.      Scanlon VC. Essentials of Anatomy and Physiology. 6th ed. F.A. Davis Company: 2011.
2.      Tanagho EA. Smith's General Urology. 17th ed. McGraw-Hill: 2008.
3.      Brooks JD. Anatomy of the lower urinary tract and male genitalia. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell Walsh-Urology. Vol 1. 9th ed. Philadelphia: WB Saunders Elsevier; 2007:Sect 1, Chap 2, pp 61-63.
4.      Reynard J. Oxford Handbook of Urology. 2nd ed. New York: Oxford University Press: 2009.

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