--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Urinary Bladder:Congenital Anomalies
trauma, cystitis, tumors, urethral trauma
--- Content provided by FirstRanker.com ---
Anatomy
The urinary bladder is a hol ow, muscular, and distensible (or elastic)
--- Content provided by FirstRanker.com ---
organ that sits on the pelvic floor .It is the organ that col ects urine excreted by the kidneys prior to
disposal by urination. Urine enters the bladder via the ureters and exits
--- Content provided by FirstRanker.com ---
via the urethra.
In males, the base of the bladder lies between the rectum and the
--- Content provided by FirstRanker.com ---
pubic symphysis. It is superior to the prostate, and separated from therectum by the rectovesical pouch.
In females, the bladder sits inferior to the uterus and anterior to the
--- Content provided by FirstRanker.com ---
vagina. It is separated from the uterus by the vesicouterine pouch.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Anatomy.................
--- Content provided by FirstRanker.com ---
EmbryologyThe urogenital sinus is formed by the division of the cloaca
by the uro-rectal septum
--- Content provided by FirstRanker.com ---
The uro-genital sinus may be divided into three component
parts.
--- Content provided by FirstRanker.com ---
cranial portion which is continuous with the al antois and forms
the bladder proper.
--- Content provided by FirstRanker.com ---
The pelvic part of the sinus forms the prostatic urethra and
epithelium as wel as the membranous urethra and bulbo
--- Content provided by FirstRanker.com ---
urethral glands in the male and the membranous urethra andpart of the vagina in females.
the caudal portion forms the penile urethra in males and the
--- Content provided by FirstRanker.com ---
vestibule in females.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Embryology........
--- Content provided by FirstRanker.com ---
The bladder forms from the cranial end of the urogenital sinus.
However, the trigone portion is formed by the caudal ends of the
--- Content provided by FirstRanker.com ---
mesonephric ducts. As the bladder expands, the mesonephric ductsbegin to become incorporated into the wal of the bladder dragging the
ureters along with them. Further growth causes the ureters to
--- Content provided by FirstRanker.com ---
eventual y have their own opening into the bladder.
The bladder is initial y continuous with the al antois. Over time, the
--- Content provided by FirstRanker.com ---
al antois degenerates to form a cord-like structure, the urachus. Theurachus goes from the umbilicus to the apex of the bladder and forms
the median umbilical ligament which can be seen in adults. The medial
--- Content provided by FirstRanker.com ---
umbilical ligaments may also be seen in adults on both sides of the
median umbilical ligament, these are the vestigial remnants of the
--- Content provided by FirstRanker.com ---
umbilical arteries.Congenital Anomalies
A major consideration with congenital abnormalities is that they tend to
--- Content provided by FirstRanker.com ---
be multiple.
Al of these anomalies are infrequent or rare, and each condition occurs
--- Content provided by FirstRanker.com ---
in both males and females
Diagnosed in infancy or childhood
--- Content provided by FirstRanker.com ---
Most are discovered in the evaluation of a urinary tract infection or, in
the case of urachal anomalies, periumbilical drainage or redness.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Classification
Urinary bladder anomalies are-
--- Content provided by FirstRanker.com ---
? bladder diverticula
? bladder ears
--- Content provided by FirstRanker.com ---
? congenital hypoplasia of the bladder? megacystis
? bladder agenesis
--- Content provided by FirstRanker.com ---
? duplication anomalies of the bladder
? bladder septa
--- Content provided by FirstRanker.com ---
Urachal anomalies areurachal sinus
urachal cyst
--- Content provided by FirstRanker.com ---
urachal diverticulum
patent urachus
--- Content provided by FirstRanker.com ---
Pathophysiology
The embryologic cause is unknown.
--- Content provided by FirstRanker.com ---
Bladder development occurs during the fifth to seventh
week of gestational development.
--- Content provided by FirstRanker.com ---
- Development depends upon many factors- mesenchymal differentiation
- mesenchymal growth
--- Content provided by FirstRanker.com ---
- urine production
Bladder cycling, the process of sequential expansion and
--- Content provided by FirstRanker.com ---
contraction, is important in the anatomic and physiologicdevelopment of the normal bladder.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Bladder Diverticulum
--- Content provided by FirstRanker.com ---
Bladder diverticula are herniations of the bladder mucosa throughbladder wal musculature (detrusor muscle).
? Diverticular size can vary
--- Content provided by FirstRanker.com ---
? Diverticula can be wide or narrow mouthed.(The size of
diverticular openings has functional implications because narrow-
--- Content provided by FirstRanker.com ---
mouthed diverticula often empty poorly).? Stasis of urine within diverticula can also lead to stone formation
or epithelial dysplasia.
--- Content provided by FirstRanker.com ---
? may cause ureteral obstruction,bladder outlet obstruction or
vesicoureteral reflux
--- Content provided by FirstRanker.com ---
Bladder Diverticulum...............MC Site lateral and superior to the ureteral orifices. [dome of the
--- Content provided by FirstRanker.com ---
bladder, in disorders as bladder outlet obstruction (ie, posterior
urethral valves) or Eagle Barrett syndrome (prune bel y
--- Content provided by FirstRanker.com ---
syndrome)].Congenital or acquired. Congenital deficiency or weakness in the
Waldeyer fascial sheath has been implicated as a cause.
--- Content provided by FirstRanker.com ---
Solitary
located at the junction of the bladder trigone and detrusor
--- Content provided by FirstRanker.com ---
Congenital diverticula are usual y removed surgical y
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Bladder Diverticula
--- Content provided by FirstRanker.com ---
Bladder ears
lateral protrusions of the bladder through the internal inguinal ring and
--- Content provided by FirstRanker.com ---
into the inguinal canal.Bladder ears are often observed during voiding cystourethrography
(VCUG) or intravenous pyelography (IVP), when the bladder is fil ed
--- Content provided by FirstRanker.com ---
to capacity.
Bladder ears have also been seen on CT body imaging.
--- Content provided by FirstRanker.com ---
No treatment is necessaryKnowledge of this entity is important to surgeons during inguinal
--- Content provided by FirstRanker.com ---
herniorrhaphy because occasional reports have been made ofpartial or near total cystectomy performed under the mistaken
notion that this was a large hernia sac.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Bladder agenesis
?
--- Content provided by FirstRanker.com ---
Rare
?
--- Content provided by FirstRanker.com ---
generally incompatible with life.?
Ureters may enter into the urethra, vagina, Gartner duct cyst
--- Content provided by FirstRanker.com ---
(female), prostatic urethra, rectum, or the patent urachus.
?
--- Content provided by FirstRanker.com ---
Associated hydroureteronephrosis and renal dysplasia(variable) are present.
?
--- Content provided by FirstRanker.com ---
Other associated anomalies include neurologic, orthopedic,
hindgut, and other urogenital anomalies, such as renal
--- Content provided by FirstRanker.com ---
agenesis and absence of the prostate, vagina, seminalvesicles, epididymis, or penis
This condition requires urinary diversion and subsequent
--- Content provided by FirstRanker.com ---
reconstruction
Megacystitis
--- Content provided by FirstRanker.com ---
Megacystitis is an enlarged bladder, believed to be secondary tooverfil ing of the fetal bladder during development
Common presentations-
--- Content provided by FirstRanker.com ---
hydronephrosis.
Febrile urinary tract infection
--- Content provided by FirstRanker.com ---
high-grade vesicoureteral refluxMegacystitis can be observed in other conditions, such as posterior
urethral valves, Ehlers-Danlos syndrome, urethral diverticulum,
--- Content provided by FirstRanker.com ---
microcolon hypoperistalsis syndrome, sacral meningomyelocele,
sacrococcygeal teratoma, and pelvic neuroblastoma.
--- Content provided by FirstRanker.com ---
Clean intermittent catheterization--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Bladder duplication
--- Content provided by FirstRanker.com ---
v Rarev Complete (2 urethras exist)
v Partial (the bladder joins distal y into one common
--- Content provided by FirstRanker.com ---
urethra)
v The 2 halves of the bladder are on either side of the midline,
--- Content provided by FirstRanker.com ---
with the corresponding ipsilateral ureter draining each bladderhalf.
v Associated anomalies include duplication of the penis, vagina,
--- Content provided by FirstRanker.com ---
uterus, lumbar vertebrae, and hindgut. fistulas may be present
between the rectum, vagina, and urethra.
--- Content provided by FirstRanker.com ---
Duplication of Ur. bladder--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Urachal cyst
--- Content provided by FirstRanker.com ---
is a fluid-fil ed structure occurring in between the two obliteratedends of the urachus.
Most occur in the distal third of the urachus.
--- Content provided by FirstRanker.com ---
More commonly, the urachal cyst is detected in early childhood or
adolescence.
--- Content provided by FirstRanker.com ---
Symptoms -infection ,inflammation,suprapubic mass, fever, pain,and bladder or irritative voiding symptoms.
? (Staphylococcus aureus is the most common bacterial organism).
--- Content provided by FirstRanker.com ---
? Death from intra-abdominal rupture has been reported.
Patent urachus
--- Content provided by FirstRanker.com ---
Communication from the umbilicus to the bladder. continuous orintermittent drainage from the umbilicus.
--- Content provided by FirstRanker.com ---
The tract may become inflamed, resulting in tenderness, periumbilical
swel ing, and serosanguinous or purulent discharge.
--- Content provided by FirstRanker.com ---
May be associated with bladder outlet obstruction, such as posteriorurethral valves.
--- Content provided by FirstRanker.com ---
Correction of the obstruction may result in the spontaneous resolutionof the patent urachus.
--- Content provided by FirstRanker.com ---
Patent Urachus
Patent Urachus
--- Content provided by FirstRanker.com ---
Resected specimen of Urachus
--- Content provided by FirstRanker.com ---
Intra-operative photograph
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Urachal sinus
--- Content provided by FirstRanker.com ---
derived from a persistently patent urachus
Children may present with
--- Content provided by FirstRanker.com ---
periumbilical tendernesswet umbilicus
granulation tissue at the level of the umbilicus
--- Content provided by FirstRanker.com ---
In many instances, these children have undergone multiple sliver nitrate
--- Content provided by FirstRanker.com ---
cauterizations under the mistaken notion that this is simplygranulation tissue after severance of the remnant umbilical cord.
These can be observed in the first 4-8 weeks of life.
--- Content provided by FirstRanker.com ---
Ectopia Vesicae
open to the outside and turned inside-out, so that its inside is visible at birth,
--- Content provided by FirstRanker.com ---
protruding from the lower abdomenSymptoms-
q Exposed posterior bladder wall
--- Content provided by FirstRanker.com ---
q Short lower abdominal wall
q Inguinal hernia
--- Content provided by FirstRanker.com ---
q Separated pubic ramiq Epispadias
q Incomplete fusion of genital tubercles
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
q Opening in abdominal wall
q Urine excretion through opening in abdominal wall
--- Content provided by FirstRanker.com ---
q Incontinence
q Dilated ureters
--- Content provided by FirstRanker.com ---
q Open pubic archq Wide-set ischial bones
q Constriction between ureter and bladder
--- Content provided by FirstRanker.com ---
q Ureteral reflux
Exostrophy of Urinary bladder
--- Content provided by FirstRanker.com ---
Cystitis
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Cystitis
--- Content provided by FirstRanker.com ---
In women is common due to a number of reasons :
- short urethra
--- Content provided by FirstRanker.com ---
- pregnancy- decreased estrogen production during menopause.
In men: mainly due to persistent bacterial infection of
--- Content provided by FirstRanker.com ---
the prostate.In both sexes: common risk factors are :
- presence of bladder stone
--- Content provided by FirstRanker.com ---
- urethral stricture
- catheterization of the urinary tract
--- Content provided by FirstRanker.com ---
- diabetes mellitusPathogenesis of cystitis
Due to frequent irritation of the mucosal surfaces of
--- Content provided by FirstRanker.com ---
the urethra and the bladder.
Infection results when bacteria ascends to the urinary
--- Content provided by FirstRanker.com ---
bladder . These bacteria are residents or transientmembers of the pereneal flora, and are derived from
the large intestine flora.
--- Content provided by FirstRanker.com ---
Toxins produced by uropathogens.
Condition that create access to bladder are:
--- Content provided by FirstRanker.com ---
- Sexual intercourse due to short urethral distance.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Pathogenesis of cystitis
--- Content provided by FirstRanker.com ---
Uncomplicated UTI usually occurred in non
pregnant , young sexually active female without
--- Content provided by FirstRanker.com ---
any structural or neurological abnormalityRisk factors :
- Catheterization of the urinary bladder ,
--- Content provided by FirstRanker.com ---
instrumentation
- structural abnormalities
--- Content provided by FirstRanker.com ---
- obstructionHematogenous through blood stream ( less
common) from other sites of infection
--- Content provided by FirstRanker.com ---
Etiologic agentsE.coli is the most common (90%) cause of cystitis.
Other Enterobacteria include ( Klebsiella pnumoniae, Proteus spp.) Other gram negative rods
--- Content provided by FirstRanker.com ---
eg. P.aeroginosa.
Gram positive bacteria :Enterococcus fecalis, group B Strept. and Staphylococcus
--- Content provided by FirstRanker.com ---
saprophyticus { honeymoon cystitis}.Candida species
Venereal diseases ( gonorrhea, Chlamydia) may present with cystitis.
--- Content provided by FirstRanker.com ---
Schistosoma hematobium in endemic areas.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Pathogens involved
Uncomplicated UTI
--- Content provided by FirstRanker.com ---
Complicated UTIE. coli
64%
--- Content provided by FirstRanker.com ---
Enterobacteriaceae 16%
E. coli
--- Content provided by FirstRanker.com ---
Enterococcus spp 20%Enterobacteriaceae
% is
--- Content provided by FirstRanker.com ---
Pseudomona spp <1%
not
--- Content provided by FirstRanker.com ---
Pseudomonas sppS. aureus
<1%
--- Content provided by FirstRanker.com ---
possibl
Acinetobacter spp
--- Content provided by FirstRanker.com ---
e toSpecial cases
(judge often multiresistant
--- Content provided by FirstRanker.com ---
strains)
(S. epidermidis)
--- Content provided by FirstRanker.com ---
S. saprophyticusYeasts (catheter related result)
--- Content provided by FirstRanker.com ---
Viruses (Adeno, Varicel a)
Chlamydia trachomatis
--- Content provided by FirstRanker.com ---
Clinical presentationSymptoms usually of acute onset
? Dysuria ( painful urination)
--- Content provided by FirstRanker.com ---
? Frequency ( frequent voiding)? Urgency ( an imperative call for toilet)
? Haematuria ( blood in urine) in 50% of cases.
? Usually no fever.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Vaginitis (5%)
--- Content provided by FirstRanker.com ---
Candida spp.
T. vaginalis
--- Content provided by FirstRanker.com ---
Cystitis (80%)Urethritis (10-
E. coli,
--- Content provided by FirstRanker.com ---
Dysuria and
15%)
--- Content provided by FirstRanker.com ---
S. saprophyticusfrequency
C. trachomatis,
--- Content provided by FirstRanker.com ---
Proteus spp.
N. gonorrhoeae
--- Content provided by FirstRanker.com ---
Klebsiella spp.H. simplex
Other bacteria?
--- Content provided by FirstRanker.com ---
Non-infectious (<1%)
Hypoestrogenism
--- Content provided by FirstRanker.com ---
Functional obstructionMechanical obstruction
Chemicals
--- Content provided by FirstRanker.com ---
How to differentiate between cystitis and
urethritis ?
--- Content provided by FirstRanker.com ---
? Cystitis is of more acute onset? More sever symptoms
? Pain, tenderness on the supra-pubic area.
--- Content provided by FirstRanker.com ---
? Presence of bacteria in urine ( bacteriuria)
? Urine cloudy, malodorous and may be
--- Content provided by FirstRanker.com ---
bloody--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Differential diagnosis
--- Content provided by FirstRanker.com ---
( types of cystitis)
Non-infectious cystitis such as:
1. Traumatic cystitis in women
--- Content provided by FirstRanker.com ---
2. Interstitial cystitis ( unknown cause, may bedue to autoimmune attack of the bladder)
3. Eosinophilic cystitis due to S.hematobium
--- Content provided by FirstRanker.com ---
4. Hemorrahagic cystitis due to radiotherapy orchemotherapy.
Laboratory diagnosis of cystitis
--- Content provided by FirstRanker.com ---
1. Specimen col ection
2. Microscopic examination
--- Content provided by FirstRanker.com ---
3. Chemical screening tests--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Recurrent cystitis
--- Content provided by FirstRanker.com ---
3 or more episodes of cystitis /yearRequires further investigations such as
--- Content provided by FirstRanker.com ---
Intravenous Urogram ( IVU) or ultrasound to detectobstruction or congenital deformity
Cystoscopy required in some cases
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Treatment of cystitis
? Empiric treatment commonly used depending on
--- Content provided by FirstRanker.com ---
the knowledge of common organism and
sensitivity pattern
--- Content provided by FirstRanker.com ---
? Treatment best guided by susceptibility patternof the causative bacteria
? Common agents: Ampicil in, Cephradine,
--- Content provided by FirstRanker.com ---
Ciprofloxacin, Norfloxacin, Gentamicin or TRM-
SMX.
--- Content provided by FirstRanker.com ---
? Duration of treatment: 3 days for uncomplicatedcystitis
? 10-14 days for complicated and recurrent cystitis
--- Content provided by FirstRanker.com ---
? Prophylaxis required for recurrent cases by
Nitrofurantoin or TRM-SMX
--- Content provided by FirstRanker.com ---
? Prevention : drinking plenty of water andprophylactic antibiotic
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Bladder cancer
--- Content provided by FirstRanker.com ---
Aetiology? Smoking ? 4x increased risk
? Causes 50% of cases
--- Content provided by FirstRanker.com ---
? Occupational ? rubber/dye industry
? Napthylamine, benzidine
--- Content provided by FirstRanker.com ---
? Schistosomiasis, chronic infection? Medications ? cyclofosfamid, fenacetin
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Histology
--- Content provided by FirstRanker.com ---
? 90-95%transitional-cell carcinoma
? 3%
--- Content provided by FirstRanker.com ---
squamos-cell carcinoma
? 2%
--- Content provided by FirstRanker.com ---
adenocarcinoma? <1%
smal -cell carcinoma
--- Content provided by FirstRanker.com ---
? 99%
primary tumors
--- Content provided by FirstRanker.com ---
Entities? 75-85% superficial bladder cancer
pTa, pTis, pT1
--- Content provided by FirstRanker.com ---
? 10-15% muscle-invasive bladder cancer
pT2, pT3, pT4
--- Content provided by FirstRanker.com ---
? 5%metastatic bladder cancer
N+, M+
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Presentation
--- Content provided by FirstRanker.com ---
? Classically painless frank haematuria,
sometimes intermittent
--- Content provided by FirstRanker.com ---
? Frequent urination, urgency? symptoms with involvement of neighbouring
organs,lymphoedema, pelvic pain
--- Content provided by FirstRanker.com ---
Examination
History
--- Content provided by FirstRanker.com ---
Physical examinationUrine examination / urinalysis, cultivation,
cytology ? can be only 60% sensitive/
--- Content provided by FirstRanker.com ---
Ultrasound
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Examination
--- Content provided by FirstRanker.com ---
? Cystoscopy is mandatory
? Biopsy or TURBT
? Bimanual pelvic examination /before and after
--- Content provided by FirstRanker.com ---
TURBT
? Chest X-ray
? IVU ? no routinely, (5% chance upper tract
--- Content provided by FirstRanker.com ---
involvement)
Bladder cancer: Stage and Prognosis
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Carcinoma in situ (CIS)
--- Content provided by FirstRanker.com ---
? Precursor infiltrating tumors
? Primary or secondary
? Subjectively ? frequent urination, urgency,
--- Content provided by FirstRanker.com ---
cystalgia
? Objectively ? no pathologies
? Laboratory
--- Content provided by FirstRanker.com ---
? Microhematuria
? Cytology positive (PAP IV-V)
CIS treatment
--- Content provided by FirstRanker.com ---
? Primary CIS: BCG
? Secondary CIS: TURB + BCG
--- Content provided by FirstRanker.com ---
? Recurrent CIS /after therapy/: cystectomy--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Treatment? Superficial Bladder Cancer
pTa, pT1, Tis
--- Content provided by FirstRanker.com ---
? Invasive bladder cancer
pT2-pT4
--- Content provided by FirstRanker.com ---
Superficial Bladder CancerpTa, pT1, Tis
Standard of care=intravesical therapy
--- Content provided by FirstRanker.com ---
transurethral resection bladder
--- Content provided by FirstRanker.com ---
tumors /TURBT/Relapse rate: 70%
--- Content provided by FirstRanker.com ---
adjuvant therapy
--- Content provided by FirstRanker.com ---
TURBT
TURBT
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
TURBT
--- Content provided by FirstRanker.com ---
Superficial Bladder Cancer
Adjuvant Therapy
--- Content provided by FirstRanker.com ---
? Reduces relapse rate by 30-80%? Mitomycin C ? in patient with
intermediate-risk BT
--- Content provided by FirstRanker.com ---
? BCG ? in patient with CIS, high risk BT
--- Content provided by FirstRanker.com ---
Invasive bladder cancer
--- Content provided by FirstRanker.com ---
? Standard of care = Radical cystectomy withpelvic lymphadenectomy
? Only about 50% of patients with high-grade
--- Content provided by FirstRanker.com ---
invasive disease are cured
Radical cystectomy
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Radical cystectomyChemotherapy for bladder cancer
? Bladder cancer is a chemosensitive disease
--- Content provided by FirstRanker.com ---
? Active single agents RR? Cisplatin
--- Content provided by FirstRanker.com ---
30%
? Carboplatin
--- Content provided by FirstRanker.com ---
20%? Gemcitabine
20-30%
--- Content provided by FirstRanker.com ---
? Ifosfamide
20%
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Neoadjuvant chemotherapy
? Meta-analysis of ten randomised trials (2688 patients)
--- Content provided by FirstRanker.com ---
? 13% reduction in risk of death
? 5% absolute benefit at 5 years
? OS increased from 45% to 50%
--- Content provided by FirstRanker.com ---
? ABC Meta-analysis Collaboration. Lancet2003;361:1927
Bladder-sparing therapy for invasive
--- Content provided by FirstRanker.com ---
bladder cancer
? High probability of subsequent distant metastasis after
--- Content provided by FirstRanker.com ---
cystectomy or radiotherapy alone (50% within 2 years)? Radiotherapy in comparison with cystectomy has inferior
results (local control 40%)
--- Content provided by FirstRanker.com ---
? muscle-invasive bladder cancer is often a systemic
disease combined modality therapy
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Bladder-sparing protocol
Transurethral resection
--- Content provided by FirstRanker.com ---
Induction Therapy: Radiation + chemotherapy
(cisplatin, paclitaxel)
Cystoscopy after 1 month
--- Content provided by FirstRanker.com ---
no tumor
tumor
--- Content provided by FirstRanker.com ---
Consolidation: RT + CTcystectomy
Urinary diversion
--- Content provided by FirstRanker.com ---
? Diversion of urinary pathway from its natural path
? Types:
--- Content provided by FirstRanker.com ---
? Temporary? Permanent
--- Content provided by FirstRanker.com ---
A nephrostomy is a
surgical procedure by
--- Content provided by FirstRanker.com ---
which a tube, stent, orcatheter is inserted
through the skin
--- Content provided by FirstRanker.com ---
into the kidney
Cutaneous
--- Content provided by FirstRanker.com ---
Ureterostomy...One kidney drainage,
with short-live
--- Content provided by FirstRanker.com ---
prognosis
Complications
--- Content provided by FirstRanker.com ---
(infection, stone,stenosis)
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Permanent urinary diversion
? Uretero ? sigmoidostomy
--- Content provided by FirstRanker.com ---
? Ileal conduit? Colon conduit
? Ileocaecaecal segment
--- Content provided by FirstRanker.com ---
Cutaneous urinary
diversions
--- Content provided by FirstRanker.com ---
Ileal conduit (ileal loop)A 12 cm loop of ileum led out
through abdominal wall
--- Content provided by FirstRanker.com ---
Stents used
The space at cystectomy site
--- Content provided by FirstRanker.com ---
drained by a drainage systemAfter surgery a skin barrier
and a transparent disposable
--- Content provided by FirstRanker.com ---
urinary drainage bag
Constantly drains
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Complications of ileal conduit? Wound infection
? Wound dehiscence
--- Content provided by FirstRanker.com ---
? Urinary leakage
? Ureteral obstruction
--- Content provided by FirstRanker.com ---
? Small bowel obstruction? Ileus
? Stomal gangrene
--- Content provided by FirstRanker.com ---
? Narrowing of the stoma
? Pyelonephritis
--- Content provided by FirstRanker.com ---
? Renal calculi--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Continent Urinary Diversions
--- Content provided by FirstRanker.com ---
? Continent Ileal Urinary ReservoirIndiana Pouch
? Most common continent urinary diversion
? Periodically catheterized
Koch Pouch
--- Content provided by FirstRanker.com ---
Ureterosigmoidostomy? Voiding occurs from rectum
Uretero-
--- Content provided by FirstRanker.com ---
sigmoideostomy--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Uretero- sigmoidostomy
? Complications:
--- Content provided by FirstRanker.com ---
? Reflux of urine? Hyperchloraemic acidosis (ammonium chloride
reabsorption, bicarbonates secretion)
--- Content provided by FirstRanker.com ---
? Renal infection
? Stricture formation
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Potential complications
--- Content provided by FirstRanker.com ---
? Peritonitis due to disruption of anastomosis
? Stoma ischaemia and necrosis due to
--- Content provided by FirstRanker.com ---
compromised blood supply to stoma? Stoma retraction and separation of
mucocutaneous border due to tension or
--- Content provided by FirstRanker.com ---
trauma
Bladder Reconstruction
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
INJURIES OF THE URINARY BLADDER
? Bladder injuries occur most often from external force and are often associated
--- Content provided by FirstRanker.com ---
with pelvic fractures.
? Iatrogenic injury may result from gynecologic and other extensive pelvic
--- Content provided by FirstRanker.com ---
procedures as well as from hernia repairs and transurethral operations.Classification
? closed and open
--- Content provided by FirstRanker.com ---
? isolated and combined
? intraperitoneal,
--- Content provided by FirstRanker.com ---
retroperitoneal and mixed.--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Clinical Findings
? There is usually a history of lower abdominal trauma.
--- Content provided by FirstRanker.com ---
? Blunt injury is the usual cause? Patients ordinarily are unable to urinate, but when
spontaneous voiding occurs, gross hematuria is usually
--- Content provided by FirstRanker.com ---
present
? Most patients complain of pelvic or lower abdominal pain.
--- Content provided by FirstRanker.com ---
Clinical Findings? Heavy bleeding associated with pelvic fracture
may result in hemorrhagic shock, usual y from
--- Content provided by FirstRanker.com ---
venous disruption of pelvic vessels.? An acute abdomen indicates intraperitoneal
bladder rupture.
--- Content provided by FirstRanker.com ---
? A palpable mass in the lower abdomen usual y
represents a large pelvic hematoma.
--- Content provided by FirstRanker.com ---
? On rectal examination, landmarks may beindistinct because of a large pelvic hematoma.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Clinical Findings? Laboratory Findings:
? Catheterization usually is required in patients
--- Content provided by FirstRanker.com ---
with pelvic trauma but not if bloody urethral
discharge is noted.
--- Content provided by FirstRanker.com ---
? When catheterization is done, gross or, lesscommonly, microscopic hematuria is usually
present.
--- Content provided by FirstRanker.com ---
? Urine taken from the bladder at the initial
catheterization should be cultured to determine
--- Content provided by FirstRanker.com ---
whether infection is present.X-Ray Findings
? A plain abdominal film generally
--- Content provided by FirstRanker.com ---
demonstrates pelvic fractures.
There may be haziness over the
--- Content provided by FirstRanker.com ---
lower abdomen from blood andurine extravasation.
? An intravenous urogram should
--- Content provided by FirstRanker.com ---
be obtained to establish whether
kidney and ureteral injuries are
--- Content provided by FirstRanker.com ---
present.--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
X-Ray Findings
--- Content provided by FirstRanker.com ---
? Bladder disruption is shown on cystography.
? Retrogradual cystography help to differentiate
--- Content provided by FirstRanker.com ---
penetrating and unpenetrating, intraperitonealand retroperitoneal ruptures of the bladder,
locate urinary flow and approximate site of
--- Content provided by FirstRanker.com ---
rupture.
? The sign of retroperitoneal rupture is
--- Content provided by FirstRanker.com ---
accumulation of X-ray contrast matter inperivesical fat tissue.
? With intraperitoneal extravasation, free
--- Content provided by FirstRanker.com ---
contrast medium is visualized in the
abdomen, highlighting bowel loops.
--- Content provided by FirstRanker.com ---
X-Ray Findings--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Treatment
--- Content provided by FirstRanker.com ---
? A. Emergency Measures:Shock and hemorrhage should be treated.
? B. Surgical Measures
--- Content provided by FirstRanker.com ---
Treatment
In a case of retroperitoneal complete rupture
--- Content provided by FirstRanker.com ---
of the bladder it is exposed by suprapubicextraperitoneal access carefully inspected
and is juncture by two-row catgut junctures.
--- Content provided by FirstRanker.com ---
Drainage by means of epicystostomy is
necessary.
--- Content provided by FirstRanker.com ---
Operation finish with drainage of perivesicaland pelvic tissue.
In order to prevent formation of urinary flow,
--- Content provided by FirstRanker.com ---
in all cases of retroperitoneal rupture of
urinary bladder, perivesical space is
--- Content provided by FirstRanker.com ---
drainage through obturatorial foramen orischiorectal space.
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Treatment
Intraperitoneal bladder ruptures should be
--- Content provided by FirstRanker.com ---
repaired via a transperitoneal approach aftercareful transvesical inspection and closure of
any other perforations.
--- Content provided by FirstRanker.com ---
The peritoneum must be closed carefully
over the area of injury.
--- Content provided by FirstRanker.com ---
The bladder is then closed in separatelayers by absorbable suture.
All extravasated fluid from the peritoneal
--- Content provided by FirstRanker.com ---
cavity should be removed before closure.
At the time of closure, care should be taken
--- Content provided by FirstRanker.com ---
that the suprapubic cystostomy is in theextraperitoneal position.
Urethral Injuries
--- Content provided by FirstRanker.com ---
? Urethral injuries are uncommon and
occur most often in men, usual y
--- Content provided by FirstRanker.com ---
associated with pelvic fractures orstraddle-type fal s.
? Various parts of the urethra may be
--- Content provided by FirstRanker.com ---
lacerated, transected, or contused.
? Management varies according to the
--- Content provided by FirstRanker.com ---
level of injury.? The urethra can be separated into 2
broad anatomic divisions: the posterior
--- Content provided by FirstRanker.com ---
urethra, consisting of the prostatic and
membranous portions, and the anterior
--- Content provided by FirstRanker.com ---
urethra, consisting of the bulbous andpendulous portions
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Clinical Findings
Symptoms:
--- Content provided by FirstRanker.com ---
? lower abdominal pain and inability to urinate. A history of crushinginjury to the pelvis is usual y obtained.
Signs:
--- Content provided by FirstRanker.com ---
? Blood at the urethral meatus is the single most important sign ofurethral injury (Urethroragia).
? Suprapubic tenderness and the presence of pelvic fracture are noted
--- Content provided by FirstRanker.com ---
on physical examination.
? A large developing pelvic hematoma may be palpated.
--- Content provided by FirstRanker.com ---
? Perineal or suprapubic contusions are often noted.? Rectal examination may reveal a large pelvic hematoma with the
prostate displaced superiorly.
--- Content provided by FirstRanker.com ---
Clinical Findings
? Laboratory Findings:
--- Content provided by FirstRanker.com ---
? Anemia due to hemorrhage may be noted.? Urine usually cannot be obtained initially, since the patient
should not void and catheterization should not be
--- Content provided by FirstRanker.com ---
attempted.--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
X-Ray Findings
Fractures of the bony pelvis are
--- Content provided by FirstRanker.com ---
usually present.
A urethrogram (using 20-30 ml of
--- Content provided by FirstRanker.com ---
watersoluble contrast material)shows the site of extravasation.
Ordinarily, there is free extravasation
--- Content provided by FirstRanker.com ---
of contrast material into the
perivesical space.
--- Content provided by FirstRanker.com ---
Incomplete prostatomembranousdisruption is seen as minor
extravasation, with a portion of
--- Content provided by FirstRanker.com ---
contrast material passing into the
prostatic urethra and bladder.
--- Content provided by FirstRanker.com ---
X-Ray Findings--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Treatment
--- Content provided by FirstRanker.com ---
? Conservative therapy is effective for
patients with recent nonpenetrating
--- Content provided by FirstRanker.com ---
damage of urethra: rest, coolcompresses, and antibiotics.
? Within 7-8 days after trauma thermal
--- Content provided by FirstRanker.com ---
procedures and resorption agents are
prescribed.
--- Content provided by FirstRanker.com ---
? In case of ischuria instead of a highcystotomy it is possible to perform
troacar epicystostomy.
--- Content provided by FirstRanker.com ---
? Shock and hemorrhage should be
treated.
--- Content provided by FirstRanker.com ---
TreatmentSurgical Measures:
? Urethral catheterization should be avoided.
--- Content provided by FirstRanker.com ---
? suprapubic cystostomy to provide urinary
drainage.
--- Content provided by FirstRanker.com ---
? The bladder should be opened andcarefully inspected for lacerations. If a
laceration is present, the bladder should
--- Content provided by FirstRanker.com ---
be closed with absorbable suture material
and a cystostomy tube inserted for urinary
--- Content provided by FirstRanker.com ---
drainage.? The suprapubic cystostomy is maintained
in place for about 3 months. This allows
--- Content provided by FirstRanker.com ---
resolution of the pelvic hematoma, and the
prostate and bladder will slowly return to
--- Content provided by FirstRanker.com ---
their anatomic positions.--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Film Suprapubic CystostomyTreatment
Urethral reconstruction ?
--- Content provided by FirstRanker.com ---
? Reconstruction of the urethra after prostatic
disruption can be undertaken within 3 months.
--- Content provided by FirstRanker.com ---
? Before reconstruction, a combined cystogramand urethrogram should be done to determine
the exact length of the resulting urethral
--- Content provided by FirstRanker.com ---
stricture.
? The preferred approach is a single-stage
--- Content provided by FirstRanker.com ---
reconstruction of the urethral rupture defectwith direct excision of the strictured area and
anastomosis of the bulbous urethra directly to
--- Content provided by FirstRanker.com ---
the apex of the prostate.
?
--- Content provided by FirstRanker.com ---
? A 16F silicone urethral catheter should be leftin place along with a suprapubic cystostomy.
? Catheters are removed within a month, and
--- Content provided by FirstRanker.com ---
the patient is then able to void
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
Re-do end to end
--- Content provided by FirstRanker.com ---
Complications
? Stricture, impotence, and incontinence are complications of prostato
--- Content provided by FirstRanker.com ---
membranous disruption.? Stricture fol owing primary repair and anastomosis occurs in about one-
half of cases. If the preferred suprapubic cystostomy approach with
--- Content provided by FirstRanker.com ---
delayed repair is used, the incidence of stricture can be reduced toabout 5%.
? The incidence of impotence after primary repair is 30-80% (mean, about
--- Content provided by FirstRanker.com ---
50%).? Incontinence in primary reanastomosis is noted in one-third of patients.
? Delayed reconstruction reduces the incidence to less than 5%.
--- Content provided by FirstRanker.com ---