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1-Evaluation of the UrologicPatient: History, Physical

Examination, and Urinalysis

HISTORYThe medical history is the cornerstone of the evaluation of the

urologic patient, and a well-taken history will frequently elucidatethe probable diagnosis

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•A complete history can be divided into the chief complaint and history of the present illness, the patient’s past medical history, and a family history.

1-Chief Complaint and Present Illness

the chief complaint is a constant reminder to the urologist as to why the patient initially sought care.

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Pain Pain arising from the GU tract may be quite severe and is usually associated with either urinary tract obstruction or inflammation

Pain of renal origin may be associated with gastrointestinal symptoms.

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Testicular Pain. Scrotal pain may be either primary or referred.

Primary pain arises from within the scrotum and is usually secondary to acute epididymitis or torsion of the testis or testicular appendices.

HematuriaHematuria is the presence of blood in the urine; greater than three red blood cells per high-power microscopic field (HPF) is significant.

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Patients with gross hematuria are usually frightened by the sudden onset of blood in the urine and frequently present to the emergency department for evaluation,fearing that they may be bleeding excessively .

Hematuria of any degree should never be ignored and, in adults, should be regardedas a symptom of urologic malignancy until proved otherwise.

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Nocturia is nocturnal frequency. Normally,adults arise no more than twice at night to void.

Dysuria is painful urination that is usually caused by inflammation.

Incontinence. Urinary incontinence is the involuntary loss of urineEnuresis. Enuresis refers to urinary incontinence that occurs during sleep.

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urinary retention and high residual urine volumes

URINALYSIS

Proteinuria

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2-Urinary Tract Imaging:Basic Principles

Imaging plays an indispensable role in the diagnosis and management of urologic

diseases .Because many urologic conditions are unable to be assessed by physical examination, conventional radiography has long been critical to the diagnosis of conditionsof the kidneys, ureters, and bladder.

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Radiation protection for medical personnel includes (1) limiting time of exposure, (2) maximizing distance from radiation source, and (3) shielding.

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PLAIN ABDOMINAL RADIOGRAPHYThe plain abdominal radiograph is a conventional radiography study, which, in urology, is intended

to display the kidneys, ureters and bladder .The plain abdominal radiograph may be employed

(1)as a primary study or (2) as a scout film in anticipation of contrast media .

(2)Plain films are widely used in the management of renal calculus disease.

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Intravascular Iodinated Contrast MediaApproximately 90% will be eliminated by the kidneys within 12 hours of administration

Approximately 85% of IA reactions occur during or immediately after injection of IRCM and are more common in patients with a prior ADR to contrast media, asthmatics, diabetics, patients withimpaired renal function or diminished cardiac function, and those who are taking β-adrenergic blockers.

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IA reactions are most concerning because they are potentially fatal and can occur without any predictable or predisposing factors.

Contrast-induced nephropathy(CIN ) 25% is defined as a rise in serum creatinine above

baseline,or more than 0.5 mg/dL within 3 days following exposure tocontrast media, in the absence of an alternative cause.

High doses of IRCM can impair renal function in some patients for 3 to 5 days. CIN in patients with normal kidney function is rare

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INTRAVENOUS UROGRAPHYOnce the mainstay of urologic imaging, the intravenous excretoryurographic (IVU) study has essentially been replaced by CT andMRI.

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Magnetic Resonance ImagingContrast AgentsBecause magnetic resonance imaging (MRI) offers previously unseen detailed soft tissue imaging compared with CT, it was initially believed that MRI would not require contrast enhancement.

However, by 2005, almost 50% of MRI studies were being performed with contrast media.

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RETROGRADE PYELOGRAPHYRetrograde pyelograms are performed to opacify the ureters andintrarenal collecting system by the retrograde injection of contrastmedia. Any contrast media that can be used for excretory urographyis also acceptable for retrograde pyelography. Attempts shouldbe made to sterilize the urine before retrograde pyelographybecause there is a risk of introducing bacteria into the upperurinary tracts or into the bloodstream.

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RETROGRADE URETHROGRAPHYA retrograde urethrogram is a study meant to evaluate the anteriorand posterior urethra. Retrograde urethrography may be particularlybeneficial in demonstrating the total length of a urethralstricture, which cannot be negotiated by cystoscopy. Retrogradeurethrography also demonstrates the anatomy of the urethradistal to a stricture, which may not be assessable by voiding

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STATIC CYSTOGRAPHYStatic cystography is employed primarily to evaluate the structural integrity of the bladder.

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VOIDING CYSTOURETHROGRAMA voiding cystourethrogram (VCUG) is performed to evaluate theanatomy and physiology of the bladder and urethra.

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ULTRASONOGRAPHYThe use of ultrasonography is fundamental to the

practice of urology .Ultrasonography is a versatile and relatively inexpensiveimaging modality that has the unique feature of being the only imaging modality to provide real-time evaluation of urologic organs and structure without the need for ionizing radiation.

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Indications1 .Assessment of renal and perirenal masses

2 .Assessment of the dilated upper urinary tract3 .Assessment of flank pain during pregnancy

4 .Evaluation of hematuria in patients who are not candidatesfor intravenous pyelography (IVP), CT, or MRI becauseof renal insufficiency, contrast allergy, or physicalimpediment

5 .Assessment of the effects of voiding on the upper urinarytract

6 .Evaluation for and monitoring of urolithiasis7 .Intraoperative renal parenchyma and vascular imaging for

ablation of renal masses8 .Percutaneous access to the renal collecting system

9 .Guidance for transcutaneous renal biopsies, cyst aspiration,or ablation of renal masses

10 .Postoperative evaluation of patients after renal and ureteralsurgery

11 .Postoperative evaluation of renal transplant patients

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NUCLEAR SCINTIGRAPHY

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COMPUTED TOMOGRAPHY

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MAGNETIC RESONANCE IMAGINGCT imaging remains the mainstay of urologic cross-sectional bodyimaging; however, MRI is increasingly being applied to the genitourinary

system .With constant improvements in technology MRI is gradually narrowing

the overall resolution quality gap between it and CT .A significant advantage of MRI is the excellentcontrast resolution of soft tissue, without the need for contrast in

many situations .Currently MRI is used when patients cannot begiven iodinated contrast and when tissue findings in the urinarysystem cannot be resolved using CT or ultrasonography

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Vicryl Synthetic Absorbable Braided 65% 2 wk40% 4 wk

Slower loss of function and higher knotbreaking

strength compared withpolyglycolic acid (Dexon)

Dexon Synthetic Absorbable Braided 63% 2 wk

17% 3 wkLubricant coating decreases coefficient of

friction

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Monocryl Synthetic Absorbable Monofilament 30%-40% 2 wk (dyed)

25% 2 wk (undyed)Excellent tensile strength allows use of

smaller sutures for skin closure

PDS Synthetic Delayed absorbable Monofilament

74% 2 wk50% 4 wk25% 6 wk

No absorption until after 90 days; lowreactivity, tends to maintain strength in

presence of infection ;

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Maxon Synthetic Delayed absorbable Monofilament

81% 2 wk59% 4 wk30% 6 wk

Chromic gut Natural Absorbable Monofilament 0% 3 wk

Can also be found as plain gut (untreated)for faster absorption

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Nylon Synthetic Nonabsorbable Monofilament 50% 1-2 yr

Very low tissue reactivity

Prolene Synthetic Nonabsorbable Monofilament

No significant loss overtime

High plasticity, extremely smooth surface(requires extra knot throws)

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Silk Natural Nonabsorbable Braided Degraded over time

Braided for easier handling; can be prone toinfection

Mersilene Synthetic Nonabsorbable Braided or

monofilamentNo significant loss over

timeBraided should not be used in infection

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Core Principles of 3-Perioperative Care

PREOPERATIVE EVALUATION

the urologic surgeon is responsible for assuring that the patient has been thoroughly evaluated by the other physicians in the health care team and presents to the operating room in the most optimized medical

condition .The preoperative use of appropriate medical specialist consults will result in improved patient safety and obviate the need for unnecessary cancelled surgeries due to the inadequacy of medical optimization.

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PRESURGICAL TESTINGOften overlooked but extremely important is the requirement for a urine pregnancy test on the morning of surgery in any woman of childbearing age unless the ovaries or uterus have been previously surgically removed

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Selection of Mode of AnesthesiaAn important role of the urologist in the anesthetic evaluation isto determine what mode of anesthesia is best for the particular

patient and surgical procedure .The choice depends on patient relatedfactors including comorbidities, airway, and patient preferenceand procedural factors including complexity, duration,

anatomic location, and expected fluid/blood loss. A basic understandingof each method of anesthesia and the pharmacologicprinciples will aid the urologist in making recommendations tothe anesthesiologist