This document provides an overview of nephrolithiasis (kidney stones) and neoplasms (tumors) of the urologic system. It discusses the presentation, evaluation, and treatment options for renal calculi, renal cell carcinoma, bladder cancer, testicular cancer, and prostate cancer. The key topics covered include the risk factors, clinical presentation, diagnostic studies such as urine analysis, CT scans, and cystoscopy, as well as treatment approaches including shockwave lithotripsy, ureteroscopy, surgery, chemotherapy, and immunotherapy.

1. Nephrolithiasis & Neoplasm
Clinical Medicine I
PA-522
Spring 2009

2. Types of Urology Lectures
Infectious diseases / bacterial infections

”….itis”, STD's

bugs and drugs

Everything else

calculus

neoplasms

prostate disease


3. Objectives
Describe the ROS associated with a GU complaint

Describe the key symptoms associated GU

complaints
Describe the presentation, evaluation and

treatments of renal calculus
Describe the presentation, evaluation and treatment

options associated with kidney, bladder, testis and
prostate cancer

4. Review of Systems
Frequency Pain with urination
 
day and night Previous history
 
Urgency GU surgery, UTIs, STDs,
 
kidney stones
Hesitancy

Family h/o cancer
Force of stream 

PSA status
Incontinence 

LMP
pad use 

Sexual complaints
Hematuria 

gross or microscopic


5. Key Symptoms
Dysuria

Pain

Hematuria


6. Dysuria
Related to acute inflammation of the bladder,

urethra, or prostate
The first symptom suggesting urinary infection

originating from a stone, contaminant, prostate

Described as a “burning” while voiding with

discomfort located in the urethra
Often associated with frequency and urgency

Don’t forget STD’s


7. Pain
Two types

Local

which is felt in or near the involved organ

Referred

originates in a diseased organ but is felt elsewhere

Kidney Prostate
Ureter Testicular
Bladder Epididymal
Bone / leg

8. Hematuria
Creates a wide variety of diagnostic possibilities

Differential diagnosis may include:

Infection
Renal calculus
Cancer
Trauma
Renal parenchymal disease

9. Hematuria
Hematuria without other symptoms

must be regarded as a tumor of the
bladder or kidney until proved
otherwise.

10. Hematuria
High power field (HPF)

0 - 3 RBC/HPF accepted

as normal
> than 3 requires

follow-up studies
UA

C&S

Cytology


11. Hematuria

12. Hematuria
Changing the focus causes RBC’s to appear as black circles

13. Hematuria timing
Partial

initial

suggests an anterior urethral lesion

terminal

suggests posterior urethral, trigone, or

bladder neck lesion
Total

present throughout urination


14. Topics to Cover
Nephrolithiasis

renal and ureteral calculus

Neoplasms

kidney, bladder, prostate, testis


15. Nephrolithiasis
Occur throughout the urinary tract

pain, infection, obstruction

Incidence

typical age range between 30 - 50 years

sex: male predominance

race: rare in African Americans

geographics: “stone belts” and developed countries

recurrences are common: 50% in 5 years

Caused by saturation and crystallization of stone-forming

salts in the urine

16. Etiology
Varies with different types of stones

calcium stones

hypercalciuria (50% of stone formers)

Idiopathic (95%) or 1 hyperparathyroidism (5%)

uric acid stones

volume depletion, acidic urine

struvite stones

form in high urinary pH (Proteus spp.)

cystine stones

Defect in the renal tubular absorption of cystine


17. Types of Calculus
Calcium 75 - 85% radiopaque

Uric acid 5 - 8% radiolucent

Cystine 1% radiolucent

Struvite 10 - 15% radiopaque

McPhee, 2003, p. 468

18. Etiology
Varies with different types of stones

calcium stones

hypercalciuria (50% of stone formers)

Idiopathic (95%) or 1 hyperparathyroidism (5%)

uric acid stones

volume depletion, acidic urine

struvite stones

form in high urinary pH (Proteus spp.)

cystine stones

Defect in the renal tubular absorption of cystine


19. Radiography
Radiopaque

applies to substances that absorb x-rays

representative areas appear white on the exposed

x-ray film
Radiolucent

applies to substances that penetrate x-rays

representative areas appear dark or black on the film


20. Radiography

21. Types of Calculus
Calcium 75 - 85% radiopaque

Uric acid 5 - 8% radiolucent

Cystine 1% radiolucent

Struvite 10 - 15% radiopaque

McPhee, 2003, p. 468

22. Presentation
Asymptomatic patients

Symptomatic / acute presentations

back pain or flank pain that waxes and wanes

pain can radiate to the groin, testicles, labia

hematuria

nausea/vomiting

dysuria


23. Flank Pain

24. Pertinent Labs and Studies
Urinalysis

Urine culture

Plain film of the abdomen

KUB

identifies radiopaque stones only (85%)

Renal U/S

Intravenous pyelogram (IVP)

CT (Spiral or Helical)


25. Urinalysis
Dipstick

Microscopic


26. IVP
A series of contrast films of the

kidneys, ureters, and bladder taken at timed
intervals after the IV injection of an iodine
containing contrast medium.
A plain film of the abdomen is taken initially.

Serial films taken at 5, 15, 30, 60, 180 minutes.


29. Acute Stone Episode Tx
Often presents in the ER

After the HPI

UA, C&S, CBC with diff, BUN, Creatinine

KUB / IVP / Spiral CT

Admission may be indicated

high grade unilateral obstruction

bilateral obstruction

obstruction of a solitary kidney

severe pain not controlled by oral analgesics


30. Treatment
Dependant on the size of the stone


31. Treatment
Stones measuring < 5 mm

Most likely to pass spontaneously

“Trial of stone passage”

Drink plenty of fluids

Increase urinary output to 2L/day

Strain urine

Oral analgesics

NSAIDs or possibly narcotic (Darvocet)

Weekly follow-up, earlier if pt. develops fever


32. Treatment
Stones measuring 5 - 10 mm

Less likely to pass spontaneously

Elective early intervention likely

especially if infection, obstruction, or solitary kidney is present

Treat as 5mm stone

ESWL or ureteroscopy with stone extraction possible.

ESWL failure: stone burden, body habitus, impaction, stone

composition

33. Treatment (5 – 10mm)
ureteroscopy
ESWL

34. Treatment
Stones measuring >10 mm

Not likely to pass

Treatment will depend

Symptoms of the patient

If Cystine or Uric acid stones then dissolution

may be possible with alkalization (ie. Potassium
citrate)
Open surgery or percutaneous endoscopic

procedure may be warranted

35. Treatment (>10mm)

36. Prevention
Regular high fluid intake

Consider diet restrictions for salt and protein

Medications

Potassium citrate (Urocit-K)

Allopurinol (Zyloprim, Aloprim)


37. Neoplasms
Kidney

Bladder

Testis

Prostate


38. Renal Neoplasms
General Characteristics

Cause unknown

# 9 of ten most common

cancers
Male:Female ratio 2:1

Occurs most commonly in the

fifth to sixth decade
RCC is the most common

malignant primary renal mass
in adults: 80%

39. Renal Tumor Presentation
Incidental / Asymptomatic presentation

50% found this way

When not found incidentally, 33% will have metastatic

disease with initial presentation
Symptomatic presentation

Pain, hematuria, weight loss, flank mass

Classic triad of flank mass, hematuria, and pain occurs in

10% of patients

40. Evaluation
UA

Cytology

CT scan with contrast

tumor is staged with CT


41. Kidney Tumor Staging
2 systems

TNM (Tumor, Nodes, Metastasis)

Robson’s classification

simplified staging system but correlated poorly with

prognosis

42. http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm

43. Treatment
Surgery is treatment of choice

Cure rate for confined local disease: 60 to 90%

RCC is relatively radioresistant

Chemotherapy trials have been disappointing

Immunotherapy trials in progress show promise


44. Bladder Cancer
Average age: 40 - 70 years

# 4 of ten most common cancers

3 times more common in men

3% of cancer related deaths in US

Risk Factors

tobacco exposure

occupational carcinogens

Rubber, dye, printing, chemical industries


45. Bladder Presentation
Hematuria

Gross

Microscopic


46. Bladder Cancer Studies
Urine for UA, C&S, cytology

IVP

Cystoscopy

TURBT


47. TURBT

48. Bladder Cancer Treatment
Stage Dependant

Superficial lesions

Resection and fulguration with f/u cystoscopy

every 3 months
Treatment with BCG

Decreases tumor recurrence and progression

Invasive or recurrent cancer

Radical cystectomy


49. BCG (Bacillus Calmette-Guerin)
Instillation into the bladder

Medication must remain for 2

hours in the bladder
Generally a series of 6

treatments
Temporary side effects

frequent urination

dysuria

flu-like symptoms

Possible systemic infection

BCG Sepsis

Conversion to PPD positive


50. Bladder Cancer Treatment
Stage Dependant

Superficial lesions

Resection and fulguration with f/u cystoscopy every 3

months
Treatment with BCG

Decreases tumor recurrence and progression

Invasive or recurrent cancer

Radical cystectomy with conduit or neobladder


51. Ileal conduit
The most commonly
used method of
urinary diversion in
the USA

52. Neobladder / Pouch
A variety of neobladders exist

53. Neobladder / Pouch

54. Testicular Cancer
Most common malignancy in young men

average age at diagnosis: 32 years

Initial presentation

painless, solid testicular swelling

“heaviness” in testis

Differential diagnosis

orchitis, hydrocele, spermatocele, testicular torsion


55. Etiology
Cryptorchidism

a condition in which a testicle is arrested at some point in

its normal descent anywhere between the renal and
scrotal areas
unilateral arrest more common than bilateral arrest

at birth the incidence of maldescent is 3.4%

half of such testicles descend in the first month of life

Trauma is not a cause of tumor

Testis tumors do not appear to have a genetic

predisposition

56. Laboratory Studies
Blood work

AFP, B-HCG: will be elevated and are diagnostic

for germ cell tumors
BUN and Creatinine: retroperitoneal disease can

cause urinary obstruction
Radiologic studies

Scrotal U/S


57. Treatment
Orchiectomy

with possible biopsy of the contralateral testis


58. Scrotal Masses
Hydrocele

fluid filled mass around testicle

transilluminates

elective surgical repair possible

Varicocele

a venous varicosity in the spermatic vein

“bag of worms”, does not transilluminate, may decrease

Testicular torsion

acute, tender, painful, scrotal swelling

surgical emergency


59. Scrotal Masses
HYDROCELE
VARICOCELE HYDROCELE
TRANSILLUMINATED

60. Prostate Cancer
The most common tumor in U.S. males: # 1

30 - 40% of men > 50 years of age have prostate

CA, although < 10% of those with prostate cancer
will die from prostate cancer
Presentation is in men usually > 65 y

Risk factors:

family history

African American

age


61. Screening for Prostate Cancer
Screening generally consists of an annual

PSA and DRE
Methods

Digital rectal exam (DRE)

begin at age 40 years, earlier for those with family hx

Serum PSA level


62. DRE
70% of all
prostate cancer
originates in the
peripheral zone

63. DRE

64. PSA
Prostate specific antigen

Nl value: 0 – 4 ng/dl

Relative risk assessment will likely supplant PSA

PSA is an enzyme made in the prostate gland

and is found in the peripheral circulation
Present in 2 forms

Bound

Free

PSA test is not diagnostic of prostate cancer


65. PSA – the good…
PSA has resulted in detecting more prostate cancers

Detects prostate cancers earlier

Will elevate with malignant conditions (cancer) as

well as infectious benign conditions (prostatitis)
Free PSA


66. PSA – the bad and the ugly
PSA test is not a foolproof test for prostate

cancer
A normal PSA does not rule out prostate cancer

Often used improperly

Started younger than necessary

Continued later than necessary

Can be masked with patients using

Finasteride up to 50%

67. PSA Value
Journal of the American Medical Association 2005;294:66-70

68. PSA Velocity
The rate of change in serum PSA

more than 0.75 ng/mL per year

the prostate cancer detection rate was 47% among

men with a PSA quot;velocityquot; greater than 0.75 ng/mL per
year versus 11% among men with a PSA velocity less
than 0.75 ng/mL per year (Smith & Catalona, 1994)

69. Free PSA

70. Prostate Evaluation - TRUS

71. Prostate Tumor Staging
2 systems

TNM (Tumor, Nodes, Metastasis)

Gleason score

one of the best tools available for predicting the

outcomes of men treated with radical prostatectomy or
with radiation therapy
prostate cancers with Gleason scores of 8 to 10 are much

more likely to recur after primary treatment than are prostate
cancers with Gleason scores of 2 to 6

72. Tannenbaum, 1977

73. Treatment
Watchful Waiting

PCPT

Finasteride reduced the risk of developing prostate cancer by

25% in men 55y and older
Radical Prostatectomy

External Beam Radiation

Radioactive Seed Implant

Cryosurgery

Hormone Therapy


74. Watchful Waiting
One approach to managing prostate cancer

Unlike other cancers, the natural progression of

prostate cancer is slow and unpredictable
Creating a difficulty in distinguishing clinically

relevant disease in the patient
Active surveillance

Another option that aims to individualize therapy


75. Watchful Waiting
Contrasts between active surveillance and watchful waiting
Watchful waiting Active surveillance
Aim To avoid treatment To individualise treatment
Age >70 or Fit for radical treatment
Patient characteristics
life expectancy <15 yrs Age 50–80
Any T stage GS ≤7 T1–T2 GS ≤7
Tumour characteristics
Any PSA Initial PSA <15
PSA testing unimportant Frequent PSA testing
Monitoring
No repeat biopsies Repeat biopsies
Short PSADT
Indications for treatment Symptomatic progression
Upgrading on biopsy
Treatment timing Delayed Early
Treatment intent Palliative Radical
Parker, 2004

76. Treatment
Watchful Waiting

Radical Prostatectomy

External Beam Radiation

Radioactive Seed Implant

Cryosurgery

Hormone Therapy


77. Objectives
Describe the ROS associated with a GU complaint

Describe the key symptoms associated GU

complaints
Describe the presentation, evaluation and

treatments of renal calculus
Describe the presentation, evaluation and treatment

options associated with kidney, bladder, testis and
prostate cancer

78. References
Course Text
Leibovich, B.C. et al. (2003). Current staging of renal cell carcinoma. Urologic Clinics
of North America, 30, 481-497.
McPhee, S.J., Lingappa, V.R., & Ganong, W.F. (2003). Pathology of disease: An
introduction to clinical medicine (4th ed.). New York: McGraw-Hill.
Parker, C. (2004). Active surveillance: towards a new paradigm in the management
of early prostate cancer. The Lancet Oncology, 5, 101-106.
Smith, D.S., & Catalona, W.J. (1994). Rate of change in serum prostate specific
antigen levels as a method for prostate cancer detection. Journal of
Urology, 152, 1163–1167.
Tanagho, E.A., & McAninch, J.W. (2004). Smith’s general urology (16th ed.). New
York: McGraw-Hill.
Tannenbaum, M. (1977). Urologic pathology: The prostate. Philadelphia: Lea and
Febiger.
Yun, E.J., Meng, M.V., & Carroll, P.R. (2004). Evaluation of the patient with
hematuria. The Medical Clinics of North America, 88, 329-343.