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Surgery_Schwartz. a Council-tip catheter via Seldinger technique; or (b) place a suprapubic tube approximately two fingerbreadths above the pubic symphysis. With regard to the suprapubic tube, ultrasound-guidance or aspiration with a finder needle should be used first to localize the bladder and avoid intra-abdominal contents, although bowel injury is unlikely with a distended bladder filling the pelvis. If hematuria is the cause of retention, continuous bladder irrigation often is necessary to prevent clot formation. This is done through a large three-way catheter that has an additional port for fluid inflow. Fluid is infused by grav-ity only because the use of higher pressure may result in bladder rupture if outflow is occluded.Once the bladder is adequately drained, the cause of AUR should be addressed. For men with suspected BPH, an α-blocker such as tamsulosin should be started, and these have been shown to increase the likelihood of a successful trial without a catheter.73 Although finasteride


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Surgery_Schwartz. For men with suspected BPH, an α-blocker such as tamsulosin should be started, and these have been shown to increase the likelihood of a successful trial without a catheter.73 Although finasteride and dutasteride (5α-reductase inhibitors) have been shown to reduce the incidence of urinary retention by 50%, they require several months to take effect and are most beneficial in large prostates; therefore, they will not provide significant benefit in the short term. Narcotics should be tapered as tolerated, and constipation should be treated.Acute spinal cord compression, which is accompanied by saddle paresthesias, is a neurologic emergency that requires neurosurgical or orthopedic consultation. In most cases, except severe neurologic injuries, patients will be able to resume void-ing, and the catheter can be removed after 1 to 2 days. Postvoid residuals should be checked with a portable ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount


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Surgery_Schwartz. catheter can be removed after 1 to 2 days. Postvoid residuals should be checked with a portable ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount of urine left after the patient tries to empty his or her bladder. In patients with severe liver dysfunction, the bladder scanner may inadvertently misinterpret ascites for urine. The inability to void or the presence of a postvoid residual over 200 mL is concerning for development of another episode of AUR. Patients may be given the option of an indwelling cath-eter for another few days with a subsequent voiding trial or to perform clean intermittent catheterization (CIC), whereby, after Brunicardi_Ch40_p1759-p1782.indd 176801/03/19 6:35 PM 1769UROLOGYCHAPTER 40Figure 40-7. Fournier’s gangrene. A. Necrotic scrotal skin from Fournier’s gangrene. B. Debridement of gangrenous tissue. Note the extensive debridement, which is commonly required. The right testicle required removal in this


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Surgery_Schwartz. A. Necrotic scrotal skin from Fournier’s gangrene. B. Debridement of gangrenous tissue. Note the extensive debridement, which is commonly required. The right testicle required removal in this case (the left is wrapped in gauze), but typically, the testes are not involved with the necrotic process.predetermined intervals (4–6 hours) or after voiding attempts, the patient passes a catheter into the bladder and empties it. This is the preferred method because it reduces the likelihood of infections from indwelling catheters and may improve blad-der functionality. However, most patients are resistant to this approach.Testicular TorsionThe differential diagnosis of acute scrotal pain includes testicu-lar torsion.74 This usually occurs in neonates or adolescent boys but may be observed in other age groups. The blood supply to the testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis, resulting in ischemia to the epididy-mis and the testis. In newborns, an


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Surgery_Schwartz. age groups. The blood supply to the testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis, resulting in ischemia to the epididy-mis and the testis. In newborns, an extravaginal torsion also can occur with twisting of the tunica vaginalis and spermatic cord together. Risk factors for torsion include undescended testis, testicular tumor, and a “bell-clapper” deformity—poor guber-nacular fixation of the testicles to the scrotal wall.Clinical history is vital for diagnosis.75 Patients describe a sudden onset of pain at a distinct point in time, with subsequent swelling. Physical examination may demonstrate a swollen, asymmetric scrotum with a tender, high-riding testicle. Children normally have a brisk cremasteric reflex that usually is lost in the setting of torsion. The diagnosis is made by clinical history and examination but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow rela-tive to the


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Surgery_Schwartz. setting of torsion. The diagnosis is made by clinical history and examination but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow rela-tive to the contralateral testis. If an ultrasound is not promptly available, timely surgical exploration should be performed.Immediate surgical exploration can salvage an ischemic testis.76 At the time of surgery, the contralateral testes also must be explored and fixed to the dartos fascia due to the pos-sibility that the same anatomic defect allowing torsion exists on the contralateral side. Midline (along the median raphe) or bilateral transverse scrotal incisions are made. Once the testis is detorsed, it should be assessed for viability after being given time for normal blood flow to resume. One can assess the blood flow using intraoperative Doppler or by incis-ing the tunica vaginalis and observing tissue viability. The testes are fixed to the dartos fascia with a small, nonabsorbable suture on


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Surgery_Schwartz. assess the blood flow using intraoperative Doppler or by incis-ing the tunica vaginalis and observing tissue viability. The testes are fixed to the dartos fascia with a small, nonabsorbable suture on their medial, lateral, and dependent aspects, taking care to ensure that the spermatic cord is not twisted before doing so. An orchiectomy should be performed to avoid later risk of abscess formation only if the testis is clearly necrotic.Fournier’s GangreneFournier’s gangrene is a necrotizing fasciitis of the male geni-talia and perineum that can be rapidly progressive and fatal if not treated promptly (Fig. 40-7). The mortality rate has been reported to be as high as 67%.77 Risk factors for Fournier’s gangrene include perirectal abscesses, diabetes, obesity, and chronic alcoholism.78 The often polymicrobial infection spreads along dartos, Scarpa’s, and Colles’ fascia. Clinical signs include perineal and scrotal pain, inflammation, necrosis, and crepitus.78 The diagnosis is largely made


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Surgery_Schwartz. polymicrobial infection spreads along dartos, Scarpa’s, and Colles’ fascia. Clinical signs include perineal and scrotal pain, inflammation, necrosis, and crepitus.78 The diagnosis is largely made on clinical suspicion; however, radiographic findings on CT imaging often assist with the diag-nosis, including soft tissue air associated with fluid collections within the deep fascia.79Prompt and aggressive surgical debridement of nonvia-ble tissue and broad spectrum antibiotics are necessary to prevent further spread (Fig. 40-7A). Fecal diversion with endorectal tubes serve as an option for conservative fecal diversion.80 If there is damage to the external anal sphincter, 67patients may require a colostomy. Patients frequently require return trips to the operating room for further debridement. Negative pressure wound therapy systems have been shown to reduce hospitalization time by aiding in wound healing.81 Reconstructive strategies involving skin grafting are needed when large tissue


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Surgery_Schwartz. Negative pressure wound therapy systems have been shown to reduce hospitalization time by aiding in wound healing.81 Reconstructive strategies involving skin grafting are needed when large tissue defects result from extensive tissue damage.PriapismPriapism is a persistent erection for greater than 4 hours unre-lated to sexual stimulation.82 Priapism is divided into two types, based on the underlying pathophysiology. The most common type—low-flow/ischemic priapism—is a medical emergency. On examination, the penis is very tender, and both cavernosal bodies will be rigid while the glans will be flaccid. Decreased venous outflow with persistent inflow results in increased intracorporal pressure and tumescence, which is the normal process of erection. Diminished arterial inflow due to elevated Brunicardi_Ch40_p1759-p1782.indd 176901/03/19 6:35 PM 1770SPECIFIC CONSIDERATIONSPART IIintrapenile pressure usually is brief under normal circumstances. Priapism is essentially a compartment


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Surgery_Schwartz. Brunicardi_Ch40_p1759-p1782.indd 176901/03/19 6:35 PM 1770SPECIFIC CONSIDERATIONSPART IIintrapenile pressure usually is brief under normal circumstances. Priapism is essentially a compartment syndrome. With pro-longed erection (priapism), the sustained decrease in arterial inflow ultimately causes tissue hypoxia, acidosis, and edema and results in long-term fibrosis and impotence, and sometimes frank necrosis. Risk factors include sickle cell disease or trait, malignancy, medications, cocaine abuse, certain antidepres-sants, and total parenteral nutrition.82-84 If a cause is not identi-fied, a hematologic workup is necessary to rule out malignancy or blood dyscrasias.The management of priapism is rapid detumescence with the goal of preservation of future erectile function. The ability to achieve normal erections is directly related to the length of the episode of priapism. Ischemic priapism can be confirmed with a penile blood gas from the cavernosal bodies demonstrating hypoxic,


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Surgery_Schwartz. to achieve normal erections is directly related to the length of the episode of priapism. Ischemic priapism can be confirmed with a penile blood gas from the cavernosal bodies demonstrating hypoxic, acidotic blood. Initial management can include sys-temic treatment of the underlying disorder (fluid and oxygen for sickle cell patients) but this should be done concurrently with an active treatment to reduce the priapism.82 The initial intervention may be therapeutic aspiration or injection of sym-pathomimetics (phenylephrine). Insertion of a large-gauge needle (16–21 gauge) into the lateral aspect of one corporal body allows thorough aspiration and irrigation of both corporal bod-ies because of widely communicating intercavernosal channels. Injection of phenylephrine (diluted 100–500 mcg/mL and given in 1 mL increments every 3–5 minutes for up to 1 hour before determining failure) into the corporal bodies works to cause vasoconstriction, but the patient should be monitored for acute


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Surgery_Schwartz. and given in 1 mL increments every 3–5 minutes for up to 1 hour before determining failure) into the corporal bodies works to cause vasoconstriction, but the patient should be monitored for acute hypertension and reflex bradycardia especially in patients with high cardiovascular risk.A surgical shunt is sometimes necessary to resolve the episode if phenylephrine fails. Distal (corporoglanular) shunts should be performed first because they are the easiest to perform and the lowest amount of complications. A Winter shunt uses a large biopsy needle to create holes between the glans and cor-pora; however, if this fails, an operative procedure can be per-formed to remove the distal tips from each corpora (Al-Ghorab). Proximal shunts such as Grayhack (corporal-saphenous vein) or Quackel (proximal cavernosumspongiosum) shunts may be required in refractory cases.The other form of priapism (high-flow/traumatic priapism) is rare and is related to penile or perineal trauma resulting in a


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Surgery_Schwartz. (proximal cavernosumspongiosum) shunts may be required in refractory cases.The other form of priapism (high-flow/traumatic priapism) is rare and is related to penile or perineal trauma resulting in a cavernous artery–corporal body fistula. This form is not painful because it is not related to ischemia and can be managed con-servatively with observation. Many cases will resolve with time; those that do not can undergo selective arterial embolization.82ParaphimosisParaphimosis is a common problem that represents a true medi-cal emergency for uncircumcised men. When the foreskin is retracted for prolonged periods, constriction of the glans penis may ensue. This is particularly likely in hospitalized patients who are confined to bed or who have altered mental status and are unable to respond to pain. Delay can be catastrophic as penile necrosis may occur due to ischemia. Penile blocks, pain medication, and sedation are sometimes necessary before manual reduction. It is useful to apply


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Surgery_Schwartz. to pain. Delay can be catastrophic as penile necrosis may occur due to ischemia. Penile blocks, pain medication, and sedation are sometimes necessary before manual reduction. It is useful to apply firm pressure to the edematous distal penis for several minutes.85 Although painful, this reduction in penile edema can be the key to success. With the fingers pulling the constricting band distally, the thumbs can push the glans penis back into normal location. Compres-sion wraps have shown some benefit without the need for the physician to use hand compression.86 If the foreskin cannot be manually reduced, surgical intervention is required.Emphysematous PyelonephritisEmphysematous pyelonephritis is a life-threatening infection that results from complicated pyelonephritis by gas-producing organisms. It is an acute necrotizing infection of the kidney that occurs predominantly in diabetic patients.87 Patients frequently present with sepsis and ketoacidosis. Escherichia coli appears to be the


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Surgery_Schwartz. It is an acute necrotizing infection of the kidney that occurs predominantly in diabetic patients.87 Patients frequently present with sepsis and ketoacidosis. Escherichia coli appears to be the most frequent organism responsible for this infection. Patients require supportive care, IV antibiotics, and relief of any urinary tract obstruction. Third-generation cephalosporins have been suggested as the initial antibiotic of choice and fluoroqui-nolones avoided due to high rates of resistance.88 Emphysema-tous pyelonephritis can be subdivided based on the extent of infection. Cases where gas is isolated to the kidney frequently can be managed conservatively with the placement of a neph-rostomy tube to allow drainage of purulent material. When there is extensive involvement of the perirenal tissue, conservative management may not be successful and strong consideration should be given to nephrectomy, particularly if the patient is displaying signs of sepsis.89,90UROLOGIC MALIGNANCIESBladder


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Surgery_Schwartz. conservative management may not be successful and strong consideration should be given to nephrectomy, particularly if the patient is displaying signs of sepsis.89,90UROLOGIC MALIGNANCIESBladder CancerEpidemiology and Presentation. In 2018, 81,190 men and women will be diagnosed with bladder cancer, and 17, 240 will die from their disease.91 The disease is highly prevalent, with over 700,000 patients living with the disease in the United States as of 2016. Men have nearly three times the incidence of women. Tobacco use is the most frequent risk factor, followed by occupational exposure to various carcinogenic materials such as industrial solvents (e.g., aromatic amines). Other risk fac-tors include arsenic, radiation, cyclophosphamide, and chronic exposure to foreign bodies (stones and catheters) and specific urinary parasites. The most common bladder cancer histology in the United States is urothelial carcinoma (UC), accounting for 90% of tumors, which tends towards a better


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Surgery_Schwartz. and catheters) and specific urinary parasites. The most common bladder cancer histology in the United States is urothelial carcinoma (UC), accounting for 90% of tumors, which tends towards a better prognosis as compared to the rarer forms, including squamous cell carcinoma (<10%), adenocarcinoma (1–2%), and small cell cancer (<1%). Unfortunately, there is no reliable screening test for bladder cancer, although patients felt to be at high risk may undergo urine sampling for microhematuria or abnormal cytology. Smoking cessation should be advised in all tobacco users as a preventive measure. The most common symptoms at presentation are hema-turia (gross or microscopic) and/or irritable voiding (urgency, frequency, and dysuria). Office cystoscopy is an effective means to diagnose bladder cancer.Staging. Clinical staging is completed with CT or MRI to assess intraabdominal nodal and visceral sites of metastasis. The upper tracts should be evaluated with CT urography or retro-grade


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Surgery_Schwartz. cancer.Staging. Clinical staging is completed with CT or MRI to assess intraabdominal nodal and visceral sites of metastasis. The upper tracts should be evaluated with CT urography or retro-grade pyelography. Chest radiograph provides initial evaluation of the thorax and mediastinum. A bone scan should be obtained if the patient complains of bone pain, has known locally advanced or metastatic disease, or an unexplained elevation in the serum alkaline phosphatase level. Pathologic staging has been outlined by the American Joint Committee on Cancer.92Transurethral resection of bladder tumor (TURBT) should include an examination under anesthesia (EUA) and sampling of the bladder muscular wall to fully assess depth of invasion. The presence of induration or a mass on EUA denotes extravesical Brunicardi_Ch40_p1759-p1782.indd 177001/03/19 6:35 PM 1771UROLOGYCHAPTER 40tumor extension and may alter the patient’s treatment plan. It may also be appropriate to biopsy multiple areas of mucosa


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Surgery_Schwartz. 177001/03/19 6:35 PM 1771UROLOGYCHAPTER 40tumor extension and may alter the patient’s treatment plan. It may also be appropriate to biopsy multiple areas of mucosa to identify multifocal carcinoma in situ (CIS). Restaging TURBT within 2 to 6 weeks is recommended in the patient with incom-plete, under-sampled, or uncertain resection. This is especially important in the patient with Tis, Ta, or T1 disease, as well as the patient with suspected T2 disease who is being considered for a bladder preservation treatment strategy. Invasion into the lamina propria and certainly the muscular wall demonstrates increased potential for distant metastases; muscle invasion is rarely treated completely with TURBT and requires additional therapy for adequate local control.Recurrence rates of non–muscle-invasive bladder can-cers are high, ranging from 50% to 70%.93 Adjuvant treatment strategies have thus been adopted after TURBT to reduce these rates. Intravesical chemotherapy used in conjunction


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Surgery_Schwartz. bladder can-cers are high, ranging from 50% to 70%.93 Adjuvant treatment strategies have thus been adopted after TURBT to reduce these rates. Intravesical chemotherapy used in conjunction with TURBT can reduce the risk of recurrence by 44% to 73% in patients with primary Ta and T1 tumors and by 38% to 65% in patients with recurrent Ta, T1, and Tis tumors when compared to TURBT alone.94 Intravesical immunotherapy using bacil-lus Calmette-Guérin (BCG) also provides a significant reduc-tion in recurrence that is greater than 50% in this population. Despite improved rates of disease-free survival, standard induc-tion courses of intravesical chemotherapy and immunotherapy do not improve disease-specific survival.94 However, when an induction course of BCG is followed by a series of maintenance doses consisting of weekly BCG given for 3 weeks at 3, 6, 12, 18, 24, 30, and 36 months after induction, disease-free and over-all survival can be prolonged.95 In patients who fail an initial or


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Surgery_Schwartz. doses consisting of weekly BCG given for 3 weeks at 3, 6, 12, 18, 24, 30, and 36 months after induction, disease-free and over-all survival can be prolonged.95 In patients who fail an initial or maintenance course of intravesical therapy, it may be rea-sonable to try another agent; however, one must consider the risk of progression and not delay definitive treatment. Roughly 15% to 30% of patients presenting with non–muscle-invasive tumors will eventually progress to muscle invasion. Radical cys-tectomy remains the most effective single-modality treatment for patients with muscle-invasive bladder cancer, refractory high-risk non–muscle-invasive disease, and especially lymph node–negative disease with a reported 10-year recurrence-free survival of organ-confined lymph node–negative (<pT2N0) dis-ease between 69% and 87%.94,96,97Surgical Considerations. Cystectomy is indicated in the treat-ment of refractory NMIBC or to assert local control for muscle invasive bladder cancer (MIBC).98


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Surgery_Schwartz. dis-ease between 69% and 87%.94,96,97Surgical Considerations. Cystectomy is indicated in the treat-ment of refractory NMIBC or to assert local control for muscle invasive bladder cancer (MIBC).98 Effective local control in the pelvis is achieved in 93% of cases with cystectomy. Indica-tions for partial cystectomy are limited and generally apply to isolated tumors or those within diverticulum. Classic teaching suggests that patients with CIS should not be candidates, though the use of intravesical BCG to treat CIS may have broadened this application. For patients with MIBC, neoadjuvant systemic chemotherapy with M-VAC or gemcitabine and cisplatin (prior to cystectomy) offers a survival advantage when compared to radical cystectomy alone.98Robotic approaches for cystectomy are increasingly used, but the urinary diversion is still usually performed through an open incision. The benefits of the robotic portion are decreased blood loss during the pelvic dissection (due to the


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Surgery_Schwartz. increasingly used, but the urinary diversion is still usually performed through an open incision. The benefits of the robotic portion are decreased blood loss during the pelvic dissection (due to the pneumoperi-toneum). However, recent evidence (randomized controlled trials of open vs. robot-assisted radical cystectomy) did not demonstrate any difference in oncologic efficacy or complica-tion rates.Complications of bladder cancer surgery involve bladder perforation during transurethral resection of the bladder tumor, which require catheter drainage for several days if small (com-mon) or open repair if large and intraperitoneal (rare). Cys-tectomy and urinary diversion may result in prolonged ileus, bowel obstruction, intestinal anastomotic leak, urine leak, or rectal injury. A urine leak from the ureteroileal anastomoses is a common cause of ileus, intra-abdominal urinoma, abscess formation, and wound dehiscence. Deep venous thrombosis is common after cystectomy due to the advanced


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Surgery_Schwartz. from the ureteroileal anastomoses is a common cause of ileus, intra-abdominal urinoma, abscess formation, and wound dehiscence. Deep venous thrombosis is common after cystectomy due to the advanced age of most patients, proximity of the iliac veins to the resection and lymph node dissection, and the presence of malignancy. The utility of subcutaneous heparin in the perioperative period can minimize the risk of venous thromboembolism. Contemporary series from high volume centers report readmission rates of 25%, complica-tion rates of 50% to 60%, and perioperative mortality in the first 90 days at 5% to 10%.99,100Urinary diversion can be accomplished using an incon-tinent or continent abdominal stoma or orthotopic continent reconstruction. The evolution of patient selection and surgical technique has led to improved outcomes for orthotopic diver-sion, although there are still patients who are better served with an ileal conduit. Motivated patients are considered for ortho-topic


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Surgery_Schwartz. technique has led to improved outcomes for orthotopic diver-sion, although there are still patients who are better served with an ileal conduit. Motivated patients are considered for ortho-topic neobladder diversion if they have a preoperative serum creatinine less than 2.0 mg/mL, normal preoperative bowel function, a negative urethral margin based on intraoperative frozen section at the time of cystectomy, and an intact sphincter after complete tumor resection.Alternatives to cystectomy include observation, systemic chemotherapy, radiation therapy, or a combination of chemo-therapy and radiation. These modalities may be required in patients who are a poor surgical risk, who refuse surgery, or who are elderly.Bladder preservation using radiation as the definitive ther-apy may be feasible in selected patients. In this context, trimo-dality therapy is preceded by aggressive TURBT and offers an improved rate of survival when performed in conjunction with chemotherapy. Up to 42% 5-year


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Surgery_Schwartz. in selected patients. In this context, trimo-dality therapy is preceded by aggressive TURBT and offers an improved rate of survival when performed in conjunction with chemotherapy. Up to 42% 5-year disease-specific survival can be achieved in patients with preserved bladders, with the best overall survival outcome in younger patients with lower stage tumors without lymphovascular or nodal involvement.More recently, immunotherapeutic treatments have shown significant promise in the treatment of locally advanced and metastatic bladder cancer. Five agents have recently been approved for patients who have progressed on or after platinum-based chemotherapy or have progressed within 12 months of neoadjuvant or adjuvant treatment. These agents include PD-L1 inhibitors (atezolizumab, avelumab, durvalumab) and PD-1 inhibitors (nivolumab and pembrolizumab). Response rates for these agents are ∼15% to 20% but may have extended median overall survival as much as 10.3 months when compared to


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Surgery_Schwartz. durvalumab) and PD-1 inhibitors (nivolumab and pembrolizumab). Response rates for these agents are ∼15% to 20% but may have extended median overall survival as much as 10.3 months when compared to chemotherapy.101,102Testicular CancerTesticular cancer is the most common cancer in men age 20 to 40 years and the second most common cancer in young men age 15 to 19 years. Metastases to the testis (usually lymphoma in older men) are rare. In 2018 there were 9310 new cases and 400 deaths from the disease.91 The incidence of testis cancer varies around the world.103 It contains a heterogeneous group of tumors, of which 95% are germ cell tumors; the rest originate from stromal cells (Leydig or Sertoli cells). Germ cell tumors can be classified as either seminomatous or nonseminomatous. Seminoma constitutes more than 50% of all testis cancer. The Brunicardi_Ch40_p1759-p1782.indd 177101/03/19 6:35 PM 1772SPECIFIC CONSIDERATIONSPART IIFigure 40-8. Scrotal ultrasound of the right testis. A


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Surgery_Schwartz. constitutes more than 50% of all testis cancer. The Brunicardi_Ch40_p1759-p1782.indd 177101/03/19 6:35 PM 1772SPECIFIC CONSIDERATIONSPART IIFigure 40-8. Scrotal ultrasound of the right testis. A heteroge-neous echoic mass is seen.incidence of bilateral GCT is approximately 2.5%.104,105 There are four established risk factors for testis cancer: cryptorchidism, family history of testis cancer, a personal history of testis can-cer, and intratubular germ cell neoplasia. Most patients present with testicular pain or a testicular mass. Respiratory symptoms, back pain, weight loss, or gynecomastia may indicate metastatic disease (10–20%). A testicular mass is considered malignant till proven otherwise. Similarly, retroperitoneal lymphadenopathy in young men should be considered metastatic testicular cancer.Standard initial workup includes scrotal ultrasound (Fig. 40-8) and serum tumor markers (α-fetoprotein, quanti-tative human chorionic gonadotropin, and lactate dehydroge-nase). Most


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Surgery_Schwartz. testicular cancer.Standard initial workup includes scrotal ultrasound (Fig. 40-8) and serum tumor markers (α-fetoprotein, quanti-tative human chorionic gonadotropin, and lactate dehydroge-nase). Most consider percutaneous biopsy contraindicated due to the rare but historical risk of disturbing the natural lymphatic drainage to the retroperitoneum and possible seeding of the scrotum.106 Radical inguinal orchiectomy is the gold standard treatment for excision of the primary tumor. Partial orchiec-tomy through an inguinal approach may be considered in some cases, including a suspected diagnosis of lymphoma. Chest and abdominal axial imaging are the main staging tools. Testicular cancer has a very predictable pattern of spread. Right testicular cancer tends to metastasize to the interaortocaval lymph node, followed by paracaval and paraaortic lymph nodes. Left-sided testicular cancer rarely crosses to the paracaval lymph nodes.107 Clinical TNM staging includes local stage, distant


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Surgery_Schwartz. lymph node, followed by paracaval and paraaortic lymph nodes. Left-sided testicular cancer rarely crosses to the paracaval lymph nodes.107 Clinical TNM staging includes local stage, distant metastasis, and tumor markers.Depending on the stage and histology of the primary tumor, multiple treatment options are available. These include active surveillance, retroperitoneal lymph node dissection (RPLND), and adjuvant chemotherapy or radiation therapy. Active surveillance for localized disease follows a tight sched-ule of physical exams, tumor markers and imaging studies. The cancer recurs in 20% to 30% of patients on active surveillance. The presence of embryonal carcinoma and vascular invasion seem to be interrelated predictors of recurrence.108 Recurrence usually occurs within the first 2 years and in the retroperito-neum.109 Pure seminoma is radiosensitive; stages I, IIa, and IIb disease can be treated with external-beam radiation to the retro-peritoneal nodes. Alternatively, a single


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Surgery_Schwartz. and in the retroperito-neum.109 Pure seminoma is radiosensitive; stages I, IIa, and IIb disease can be treated with external-beam radiation to the retro-peritoneal nodes. Alternatively, a single dose of carboplatin for stage I seminoma was found to be just as effective as radiation therapy.110 More advanced seminoma is treated with platinum-based systemic chemotherapy.Stages I to IIA nonseminomatous testis cancer is poten-tially cured with RPLND or chemotherapy.111 Persistently high tumor markers after radical orchiectomy or high-stage meta-static germ cell tumors warrant systemic chemotherapy. Due to the high rates of teratoma or viable germ cell tumor, postchemo-therapy bulky masses are resected by RPLND or other surgi-cal procedures. The overall survival rate of localized disease is outstanding (99% at 5 years). Patients with more advanced distant metastatic disease (stage III) have 75% survival rates. The overall prognosis is generally better for seminomatous than nonseminomatous


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Surgery_Schwartz. (99% at 5 years). Patients with more advanced distant metastatic disease (stage III) have 75% survival rates. The overall prognosis is generally better for seminomatous than nonseminomatous germ cell tumors.112Surgical Considerations. Radical orchiectomy is done through an inguinal incision extending from the external inguinal ring to the internal inguinal ring. The spermatic cord is ligated at the internal ring with long silk sutures for easier identification during a future RPLND. Integrity of the scrotal skin during orchiectomy is important. Complications of radi-cal orchiectomy include scrotal hematoma, chronic pain, and hernia.For RPLND, a midline incision is usually made from the xiphoid process to the pubic symphysis. All the lymphatic tissue is removed from the targeted areas using the classical split and roll technique, and all lumbar vessels are tied. Postganglionic sympathetic nerve sparing is possible in most cases for pres-ervation of ejaculatory function.113


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Surgery_Schwartz. areas using the classical split and roll technique, and all lumbar vessels are tied. Postganglionic sympathetic nerve sparing is possible in most cases for pres-ervation of ejaculatory function.113 Robotic-assisted RPLND is growing, with faster recovery time and similar short term oncologic results.114 Complications after RPLND include bowel obstruction, excessive bleeding, chylous ascites, and ejaculatory dysfunction.Kidney CancerRenal cell carcinoma (RCC) results in approximately 3.8% of all new cancers, with an estimated 65,340 new cases and 14,970 deaths related to kidney cancer in 2018.91 Despite several advancements with immune-based and targeted molecular ther-apies demonstrating durable clinic responses, RCC still remains primarily a surgical disease and classically does not respond to conventional chemotherapy regimens or radiation therapy.Most patients diagnosed with RCC in the modern era typically present with an incidentally discovered renal mass on abdominal radiographic


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Surgery_Schwartz. to conventional chemotherapy regimens or radiation therapy.Most patients diagnosed with RCC in the modern era typically present with an incidentally discovered renal mass on abdominal radiographic imaging. Differential diagnosis of a renal mass includes malignant tumors (e.g., RCC, urothelial carcinoma, sarcomas, lymphoma, metastasis), benign tumors (e.g., cysts, angiomyolipoma, oncocytoma), and inflammatory lesions (e.g. abscesses, xanthogranulomatous pyelonephritis, tuberculosis). Renal CT imaging with intravenous contrast remains the single most important radiographic test to delineate the nature of the mass. In general, any solid renal mass that enhances by more than 15 Hounsfield units is an RCC until proven otherwise. However, even if there is contrast enhance-ment on axial imaging, approximately 15% to 30% of solid renal masses are benign on final surgical pathology.115 Renal tumor biopsy can help distinguish between malignant or benign tumors, but this has not been widely


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Surgery_Schwartz. approximately 15% to 30% of solid renal masses are benign on final surgical pathology.115 Renal tumor biopsy can help distinguish between malignant or benign tumors, but this has not been widely adopted by the urological community, despite series showing their high diagnostic yield, concordance with surgical pathology, and safety.116-118 Biopsy remains particularly useful in patients considering surveillance or thermoablative therapy, or in patients with suspicion of metastasis or lymphoma.Major recognized risk factors for RCC include smoking, obesity, and hypertension. Although most RCCs are discovered incidentally, some patients present with signs or symptoms Brunicardi_Ch40_p1759-p1782.indd 177201/03/19 6:35 PM 1773UROLOGYCHAPTER 40which may be the result of local tumor growth (e.g., flank pain, hematuria, perirenal hematoma), paraneoplastic syndromes (e.g., hypertension, weight loss, hypercalcemia, polycythemia/anemia, abnormal liver function tests), or metastatic disease. RCC


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Surgery_Schwartz. flank pain, hematuria, perirenal hematoma), paraneoplastic syndromes (e.g., hypertension, weight loss, hypercalcemia, polycythemia/anemia, abnormal liver function tests), or metastatic disease. RCC metastasizes primarily to the lungs, lymph nodes, bone, liver, adrenal glands, and brain. Familial RCC subtypes with classical clinical manifestations are also well described. The von Hippel-Lindau disease, occurring as a result of a mutation in the tumor suppressor gene VHL (3p25-26), commonly mani-fests itself with clear cell RCC, pheochromocytomas, retinal angiomas, central nervous system hemangioblastomas, pancre-atic cysts, and other tumors. Other familial syndromes include hereditary papillary RCC (papillary type 1 RCC), familial leiomyomatosis (papillary type 2 RCC), and Birt-Hogg-Dube syndrome (chromophobe RCC, hybrid oncocytic tumors, and oncocytoma). Familial RCC syndromes should be suspected in younger patients and patients with multicentric and/or bilateral tumors.Clear cell RCC


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Surgery_Schwartz. (chromophobe RCC, hybrid oncocytic tumors, and oncocytoma). Familial RCC syndromes should be suspected in younger patients and patients with multicentric and/or bilateral tumors.Clear cell RCC is the most common subtype, accounting for 70% to 80% of all RCCs. Papillary RCC occurs in 10% to 15%, type 1 being associated with a better prognosis, and type 2 a worse prognosis. Other subtypes include chromophobe RCC, collecting duct carcinoma, and unclassified type.RCC may locally progress and cause invasion of the renal capsule and perirenal fat or the collecting system. RCC may also directly progress into the venous system in the form of a tumor thrombus that can extend into the IVC and into the right atrium. Staging is the single most important prognostic factor for RCC.119,120 Studies demonstrate a 70% to 90% 5-year survival rate for organ confined disease (stages I–II), compared to 0% to 10% for patients with systemic metastases (stage IV).119 Other important prognostic factors include


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Surgery_Schwartz. a 70% to 90% 5-year survival rate for organ confined disease (stages I–II), compared to 0% to 10% for patients with systemic metastases (stage IV).119 Other important prognostic factors include histological subtype,121 tumor size, lymph node involvement, and site of metastases.122Management options for small renal masses (<4 cm) includes active surveillance, thermoablative techniques, or sur-gical excision (Fig. 40-9). Percutaneous or laparoscopic ther-moablative techniques (cryoablation, radiofrequency ablation, high-intensity focused ultrasound) have been used to treat small renal masses, but they are associated with an increased risk of local recurrence.123,124Since the first laparoscopic radical nephrectomy described by Clayman et al in 1991,125 minimally invasive Figure 40-9. Computed tomography scan of the abdomen with intravenous and oral contrast. A small mid right posterior mass is seen.Figure 40-10. Intraoperative image of a small renal mass in prepa-ration for partial


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Surgery_Schwartz. tomography scan of the abdomen with intravenous and oral contrast. A small mid right posterior mass is seen.Figure 40-10. Intraoperative image of a small renal mass in prepa-ration for partial nephrectomy.surgical approaches, including laparoscopy with robotic assis-tance, have virtually supplanted open procedures for localized RCC (Fig. 40-10). Partial nephrectomy is most appropriate for patients with small tumors, solitary kidney, bilateral tumors, or familial RCC. Some tumors may not be amenable to abla-tive therapies or partial nephrectomy, in which case radical nephrectomy would be employed.126Radical nephrectomy involves removal of the entire kidney with dissection external to Gerota’s fascia. The colon is retracted medially after incising the white line of Toldt, fol-lowed by meticulous hilar dissection with ligation of the renal artery and vein. The adrenal gland is usually spared unless the tumor involves the gland or is immediately adjacent to it. Lymphadenectomy remains


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Surgery_Schwartz. hilar dissection with ligation of the renal artery and vein. The adrenal gland is usually spared unless the tumor involves the gland or is immediately adjacent to it. Lymphadenectomy remains controversial, and it is usually per-formed in patients with adenopathy on preoperative imaging or in patients with palpable lymph nodes intraoperatively. In partial nephrectomy, renal artery clamping is often performed to minimize blood loss while the tumor is excised. The goal is to remove the tumor with negative surgical margins while minimizing warm ischemia time to preserve as many func-tional nephrons as possible. With increasing experience, partial nephrectomy is now also performed on much more complex renal masses, including completely endophytic, central, and hilar tumors. Very large tumors or tumors with vena-caval thrombi can be removed robotically in experienced hands,127,128 but most are still removed using an open approach.In minimally invasive surgery, both partial and radical


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Surgery_Schwartz. or tumors with vena-caval thrombi can be removed robotically in experienced hands,127,128 but most are still removed using an open approach.In minimally invasive surgery, both partial and radical nephrectomy can be done via either a transperitoneal or retro-peritoneal approach. In open cases, a subcostal flank approach provides direct access to the retroperitoneum and is preferred for lower pole exposure, but it can limit access to the hilum, particularly with large renal masses. The anterior subcostal approach is preferred for larger renal masses. Bilateral ante-rior subcostal incisions (chevron incision) provides excellent vascular exposure (e.g., IVC thrombectomy, bilateral tumors). Midline incisions are usually reserved for renal trauma and for reconstructive procedures. Less commonly performed, the thoracoabdominal approach involves access usually above the 10th rib and is used for large upper pole or adrenal masses, IVC thrombectomy, or tumors involving adjacent structures.


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Surgery_Schwartz. performed, the thoracoabdominal approach involves access usually above the 10th rib and is used for large upper pole or adrenal masses, IVC thrombectomy, or tumors involving adjacent structures. Complications include injury to adjacent organs, and for partial nephrectomy, pseudoaneurysms/arteriovenous fistula formation and delayed urinary leak.Brunicardi_Ch40_p1759-p1782.indd 177301/03/19 6:35 PM 1774SPECIFIC CONSIDERATIONSPART IIProstate CancerProstate cancer is the most common noncutaneous cancer in men; 164,690 new cases of prostate cancer were diagnosed in 2018 and 29,430 men died from their disease.91 Screening for prostate cancer with detailed history, digital rectal examination, and serum prostate specific antigen (PSA) tests have changed the natural history of the disease. Since the introduction of pros-tate cancer screening in the mid-1980s, the incidence of meta-static prostate cancer has decreased by half. Currently 99% of newly diagnosed patients will survive more than


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Surgery_Schwartz. the introduction of pros-tate cancer screening in the mid-1980s, the incidence of meta-static prostate cancer has decreased by half. Currently 99% of newly diagnosed patients will survive more than 10 years.91While early screening for African American patients or patients with a family history of prostate cancer is widely accepted, screening for all men is more controversial. Despite data from large randomized clinical trials showing a decrease in mortality after prostate cancer screening, the U.S. Preventive Services Task Force recommended against the routine use of prostate cancer screening.129 Its recommendation was based on the harm and toxicity of overtreatment of nonlethal disease.130 The American Urologic Association subsequently recom-mended informed and shared decision-making and screening for high-risk disease for men between the ages of 55 and 69 with a life expectancy more than 10 years.131If the digital rectal examination is abnormal or if the PSA level is above expected


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Surgery_Schwartz. screening for high-risk disease for men between the ages of 55 and 69 with a life expectancy more than 10 years.131If the digital rectal examination is abnormal or if the PSA level is above expected for patients’ age and size of the prostate, a prostate biopsy is usually performed. Newer tests such as the 4K score, prostate health index, and PCA3 are sometimes used to inform the decision to proceed with biopsy. Recently, MRI fusion transrectal ultrasound-guided biopsy improved the accu-racy of prostate biopsy.Since most patients survive the disease, risk stratification systems are routinely utilized to guide staging and treatment. Clinical TNM stage, serum PSA levels, and the Gleason grading system are utilized in clinical practice. More recently, genetic testing on biopsy specimen was included in national guidelines. Historically, the Gleason scoring (GS) system included a pri-mary and secondary score based on the most common and sec-ond most common histologic patterns. Grades range


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Surgery_Schwartz. in national guidelines. Historically, the Gleason scoring (GS) system included a pri-mary and secondary score based on the most common and sec-ond most common histologic patterns. Grades range from 1 for the most differentiated to 5 for the least. The grades are added to create a resultant Gleason score.132 However, since no patients are assigned a score of less than 5 anymore, the grading system has been modified to a scale from 1 to 5. Grade one includes a GS of 3 + 3 = 6 or less, grade 2 for GS 3 + 4, grade 3 for GS 4 + 3, grade 4 for GS 4 + 4 and grade 5 for Gleason score of 9 or 10.133 Imaging studies like CT and bone scans are used to rule out metastatic disease in high-risk patients. The two most common sites of metastatic disease are pelvic/retroperitoneal lymph nodes and boney structures. Modern CT PET scans have a limited role at this point.Treatment for localized prostate cancer is guided by can-cer aggressiveness and patient’s preferences. Active sur-veillance is


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Surgery_Schwartz. boney structures. Modern CT PET scans have a limited role at this point.Treatment for localized prostate cancer is guided by can-cer aggressiveness and patient’s preferences. Active sur-veillance is recommended for patients with low-risk disease grade 1–2, early-stage disease (cT1c), and small volume disease as determined by biopsy. Large prospective cohorts and randomized clinical trials have established the safety of this approach.134,135 The risk of progression to metastatic disease with close follow-up and repeat prostate biopsies is less than 2% in over 12 years. Radical prostatectomy and pelvic lymph node dissection (robotic, laparoscopic, or open), image modulated radiation therapy (IMRT), and brachytherapy are the standard of care for curative treatments. All provide equal cancer specific survival for low and intermediate risk cancers. For higher risk prostate cancer patients, both surgery and IMRT with androgen 8Figure 40-11. The da Vinci Surgical System used commonly for


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Surgery_Schwartz. specific survival for low and intermediate risk cancers. For higher risk prostate cancer patients, both surgery and IMRT with androgen 8Figure 40-11. The da Vinci Surgical System used commonly for radical prostatectomy.deprivation therapy provide excellent cancer control. Cryother-apy, or high intensity focused ultrasound (HIFU) and focal therapy are emerging options that may be acceptable for some patients with low-risk disease.Level I evidence has established the role of adjuvant radia-tion therapy after radical prostatectomy for patients with posi-tive surgical margins, extracapsular extension, and high-grade disease.136,137 After definitive treatment of localized prostate cancer, rising PSA is an extremely reliable indicator of recur-rence or progression. However, it may take over 10 years for metastasis to appear on imaging studies.138 Once prostate cancer metastasizes, it is no longer curable. Medications that lower serum testosterone or androgen receptor blockers are able to


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Surgery_Schwartz. years for metastasis to appear on imaging studies.138 Once prostate cancer metastasizes, it is no longer curable. Medications that lower serum testosterone or androgen receptor blockers are able to control the disease, often for years. In addition, chemotherapy, immunotherapy, and radioisotope therapy at different stages of the disease increase the life expectancy of the patients or improve the quality of life. The cancer inevitably becomes resis-tant to these treatments. Nevertheless, patients with incurable prostate cancer can live many years, and a large number die of causes other than prostate cancer.Over the past few years, we have witnessed major devel-opments in the management of metastatic castrate resistant prostate cancer (mCRPC). New agents that interrupt androgen synthesis (e.g., abiraterone acetate)139,140 and new modulators of androgen receptors (e.g., enzalutamide)141,142 have significantly improved the life expectancy of patients with both androgen sensitive and


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Surgery_Schwartz. (e.g., abiraterone acetate)139,140 and new modulators of androgen receptors (e.g., enzalutamide)141,142 have significantly improved the life expectancy of patients with both androgen sensitive and resistant metastatic prostate cancer. Similarly, innovations in immunotherapy and chemotherapy delivery have advanced the management of advanced prostate cancer.Surgical Considerations. Open radical retropubic prostatec-tomy is done through a lower midline incision from below the umbilicus to the pubic symphysis. After entering the space of Retzius, the external iliac, obturator, and internal iliac lymph nodes are removed. The cavernosal nerves located on the pos-terolateral surface of the prostate capsule are usually spared on the side(s) with low risk of extracapsular extension of the dis-ease. Then the prostate is removed in a retrograde fashion, and the urethrovesical anastomosis is completed in an interrupted fashion.Robotic radical prostatectomy using the da Vinci robotic surgical


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Surgery_Schwartz. Then the prostate is removed in a retrograde fashion, and the urethrovesical anastomosis is completed in an interrupted fashion.Robotic radical prostatectomy using the da Vinci robotic surgical system (Fig. 40-11) is now the most common tech-nique (over 90% of all patients in the United States) for the Brunicardi_Ch40_p1759-p1782.indd 177401/03/19 6:35 PM 1775UROLOGYCHAPTER 40surgical treatment of localized prostate cancer. Robotic surgery has lower blood loss and faster convalescence, less bladder neck contracture, and lower early postoperative complications. Some data show a faster return of continence and lower rates of erectile dysfunction. The most common postoperative compli-cations include infection, urine leaks, ileus, lymphocele, and, very rarely, rectal or ureteral injury.To minimize the impact of these side effects, researchers have used different ablative techniques to obliterate the areas of significant cancer. By avoiding the need for whole gland radia-tion or


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Surgery_Schwartz. minimize the impact of these side effects, researchers have used different ablative techniques to obliterate the areas of significant cancer. By avoiding the need for whole gland radia-tion or removal, these focal ablative therapies aim to balance the long-term impact on quality of life with survival. Laser, high-focused ultrasound, cryotherapy, and photodynamic ablations have showed similar results in early studies.Urethral CancerUrethral carcinoma (UC) is a rare disease, the true incidence of which is unknown. It accounts for less than 1% of genito-urinary cancers.143,144 It is a disease of the older adult. Risk fac-tors include chronic inflammation from sexually transmitted diseases (human papillomavirus 16 and 18 in squamous cell carcinoma),145 chronic urethral stricture, and indwelling cath-eterization. Furthermore, urethral diverticulum and recurrent urinary tract infections increase the risk for women.The majority of patients present with irritative and obstructive voiding


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Surgery_Schwartz. cath-eterization. Furthermore, urethral diverticulum and recurrent urinary tract infections increase the risk for women.The majority of patients present with irritative and obstructive voiding symptoms, bleeding, or a palpable mass. Urothelial carcinoma is the most common histology; 29% of women have adenocarcinoma, and both genders can have squamous cell carcinoma. Untreated or refractory UC typically metastasizes through lymphatic channels to the inguinal and pelvic lymph nodes and hematologically to distant organs. Cys-toscopic biopsy establishes the diagnoses. An MRI of the pelvis is extremely helpful for defining local extension of the disease while CT scans of the chest, abdomen, and pelvis identify meta-static disease. Finally, it is also important to evaluate the entire urinary tract.The 5-year overall survival rates for distal urethral tumors is significantly better than for proximal cancers, 68% versus 40%, respectively.143,146 The median 5-year cancer-specific sur-vival is


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Surgery_Schwartz. 5-year overall survival rates for distal urethral tumors is significantly better than for proximal cancers, 68% versus 40%, respectively.143,146 The median 5-year cancer-specific sur-vival is approximately 46%.144 Prognosis is dictated by patients’ age, race, clinical stage, and location of the tumor.If feasible, local endoscopic resection for low-volume, low-stage disease is preferable. Adjuvant intravesical instilla-tion of Bacillus Calmette-Guérin (BCG) should be considered for patients with proximal noninvasive disease.147 Due to the paucity of robust data, management of locally advanced dis-ease is more challenging. Either radical cystectomy or radiations are acceptable options. Unfortunately, local recurrence rates are high after aggressive monotherapy (63%).148 More recent data support the use of multimodal therapy.149,150 Small series of combinations of perioperative chemotherapy, surgery, and radiation indicate the best cancer control.151COMMON UROLOGIC CONDITIONSUrinary


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Surgery_Schwartz. support the use of multimodal therapy.149,150 Small series of combinations of perioperative chemotherapy, surgery, and radiation indicate the best cancer control.151COMMON UROLOGIC CONDITIONSUrinary Incontinence and Voiding DysfunctionUrinary incontinence is defined as the involuntary loss of urine. This is more common in women than men for a variety of rea-sons, including anatomic differences such as a shorter urethra and risk factors such as childbirth. Many patients may also suf-fer from bothersome symptoms without leakage of urine such as overactive bladder (frequency and urgency of urination and often nocturia), or obstructive symptoms such as hesitancy, weak stream, and incomplete bladder emptying. These condi-tions can have a negative impact on quality of life,152-154 but they are also associated with serious health issues, including depres-sion, anxiety, social isolation,155 and even falls and fractures in the elderly.156Urinary incontinence can be divided into several


Surgery_Schwartz

Surgery_Schwartz. are also associated with serious health issues, including depres-sion, anxiety, social isolation,155 and even falls and fractures in the elderly.156Urinary incontinence can be divided into several catego-ries, although patients (particularly women) may suffer from more than one type.157 Urge incontinence is the involuntary loss of urine associated with an urge to void. Stress leakage occurs with increases in intra-abdominal pressure, such as coughing or sneezing, and may relate to loss of sphincteric function, urethral hypermobility from pelvic floor laxity (often related to parity), or following prostate surgery in men. Overflow incontinence occurs in the setting of obstruction, with urine leakage occurring with movement causing over-flow of urine from a distended bladder. Genitourinary fistulas typically result in the most severe form of incontinence with constant leakage of urine regardless of presence or absence of activity or movement. Examples include vesicovaginal or


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Surgery_Schwartz. fistulas typically result in the most severe form of incontinence with constant leakage of urine regardless of presence or absence of activity or movement. Examples include vesicovaginal or ureterovaginal fistulae most often due to gynecologic surgery, or rectourethral fistulae in men from cancer, radiation, or sur-gical intervention.Treatments for urinary incontinence and voiding dysfunc-tion are varied depending on the etiology, severity, and bother of the symptom. Urge leakage and overactive blad-der can be treated by (a) behavioral modification (timed void-ing, adjustment to fluid intake, timing of diuretic medication, and improved constipation); (b) bladder retraining (pelvic floor physical therapy158); (c) medications (anticholinergics159 and β-3 agonists160); or (d) minimally invasive procedures (sacral neuro-modulation,161 percutaneous tibial nerve stimulation,162 or blad-der chemodenervation with detrusor botulinum toxin injection163).Stress incontinence in women can be


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Surgery_Schwartz. invasive procedures (sacral neuro-modulation,161 percutaneous tibial nerve stimulation,162 or blad-der chemodenervation with detrusor botulinum toxin injection163).Stress incontinence in women can be addressed by pelvic floor strengthening exercises, vaginally placed removable sup-port with a pessary, injection of urethral bulking agent, or sling procedures using polypropylene mesh or autologous tissue. In men, stress leakage is due to either iatrogenic causes or neuro-logic disease. Treatments include strengthening exercises as in women, slings, or implantation of an artificial urinary sphincter. Overflow incontinence treatment is directed at the cause of obstruction, often benign prostatic enlargement in men, with bladder drainage, medications such as α-blockers or 5-α reduc-tase inhibitors, or surgical removal of the obstructing gland. When fistulas are present, adherence to surgical principles such as tension-free multilayer closure, nonoverlapping suture lines, and tissue


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Surgery_Schwartz. inhibitors, or surgical removal of the obstructing gland. When fistulas are present, adherence to surgical principles such as tension-free multilayer closure, nonoverlapping suture lines, and tissue interposition when possible offers the highest likeli-hood for success.Erectile DysfunctionErectile dysfunction (ED) is defined as the inability to achieve and maintain an erection adequate for sexual intercourse. For-merly, this was known as a type of sexual dysfunction, but it is now understood that ED may be an early symptom of cardiovas-cular disease due to endothelial dysfunction. ED is a common disease for men later in life with a prevalence rate believed to range anywhere from 30% to 50% depending on age. Two large population-based studies, the Massachusetts Male Aging Study (MMAS) and the European Male Aging Study (EMAS), exam-ined men age 40 to 79 years and found that ED rates increased with age.164,1659Brunicardi_Ch40_p1759-p1782.indd 177501/03/19 6:35 PM 1776SPECIFIC


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Surgery_Schwartz. and the European Male Aging Study (EMAS), exam-ined men age 40 to 79 years and found that ED rates increased with age.164,1659Brunicardi_Ch40_p1759-p1782.indd 177501/03/19 6:35 PM 1776SPECIFIC CONSIDERATIONSPART IIErections are triggered via sexual stimulation setting off a cascade of events. Nitric oxide is released from nerve fibers and activating guanylyl cyclase leading to an increase in cyclic guanosine monophosphate (cGMP). The cGMP pathway leads to smooth muscle relaxation within the corpora cavernosa allow-ing blood to fill the lacunar spaces. Once the lacunar spaces are full, the expanded tissue compresses the subtunical venules thereby trapping blood within the penis and blocking venous out-flow. Phosphodiesterase type-5 hydrolyzes cGMP to reverse the process.166There are multiple mechanisms leading to ED including vasculogenic, neurogenic, iatrogenic, and psychologic, but often it is multifactorial. Vasculogenic ED can be a result of cardiovascular disease and


Surgery_Schwartz

Surgery_Schwartz. are multiple mechanisms leading to ED including vasculogenic, neurogenic, iatrogenic, and psychologic, but often it is multifactorial. Vasculogenic ED can be a result of cardiovascular disease and endothelial dysfunction leading to cavernosal artery insufficiency. Diseases such as hypertension (odds ratio [OR] 1.35–3.04), diabetes (OR 2.57), dyslipidemia (OR 1.83), and tobacco abuse (OR 1.4) all may increase the risk for ED.167 Nerve injuries due to diseases (diabetes, Parkin-son’s, multiple sclerosis, spinal cord injury) or surgery (radical prostatectomy, abdominoperineal resection, and other radical pelvic procedures) can lead to interruptions in the nerve signal-ing that causes nitric oxide release and therefore lead to ED. Iatrogenic causes may be a result of surgery (described earlier) or medication use, as in some antihypertensives, opiates, anti-androgens, and psychotherapeutics.168 Psychogenic ED, a com-mon reaction to stress and anxiety, is a result of noradrenaline release


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Surgery_Schwartz. or medication use, as in some antihypertensives, opiates, anti-androgens, and psychotherapeutics.168 Psychogenic ED, a com-mon reaction to stress and anxiety, is a result of noradrenaline release causing smooth muscle contraction and thereby inhibit-ing erections.169Treatment for ED begins with lifestyle modification by identifying any reversible risk factors such as stress/anxiety, medications, unhealthy diets, lack of exercise, and tobacco abuse.170 Medical therapy then begins with the use of phospho-diesterase type-5 inhibitors (PDE5i). These work by prolonging the activity of cGMP, leading to continued smooth muscle relax-ation allowing more blood inflow into the penis. Common drugs include sildenafil, tadalafil, vardenafil, and avanafil. They differ in time to peak concentration (lowest in avanafil, sildenafil, and vardenafil), half-life (highest in tadalafil), and the impact of lip-ids in foods (sildenafil and vardenafil must be taken on an empty stomach). Common side effects


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Surgery_Schwartz. in avanafil, sildenafil, and vardenafil), half-life (highest in tadalafil), and the impact of lip-ids in foods (sildenafil and vardenafil must be taken on an empty stomach). Common side effects include a headache, heartburn, facial flushing, nasal congestion, and myalgias.171 Patients on nitrate-containing medications should not be given PDE5i due to the risk of severe hypotension. Vision related conditions like macular degeneration, retinitis pigmentosa, and nonarter-itic anterior ischemic optic neuropathy are cause for increased awareness and possible ophthalmologic consult.172Second-line options for ED include vacuum erection devices (VED), intracavernosal injections (ICI), and intraure-thral suppositories. The VED is a mechanical device composed of a cylinder placed around the penis which then uses a vacuum to create negative pressure and pull blood into the penis. In order for blood to stay in the penis after the vacuum is released, a tight constriction band must be placed at the


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Surgery_Schwartz. then uses a vacuum to create negative pressure and pull blood into the penis. In order for blood to stay in the penis after the vacuum is released, a tight constriction band must be placed at the base of the penis. There is poor compliance due to difficulty with use and the common reactions of petechia, temporary paresthesia, color changes, and the penis being cold to touch.173,174 Alternatively, ICI uses vasoactive substances (prostaglandin E1 [alprostadil], papaverine, and phentolamine) either alone or in combination to trigger the erection cascade.168 Patients are trained to give themselves a self-injection when they want an erection, and it takes approximately 5 to 15 minutes until they are fully rigid if they respond. With ICI, there is greater concern for prolonged Figure 40-12. A three-piece penile implant for the treatment of erectile dysfunction. The prosthesis is composed of two cylinders placed in the penis, a fluid reservoir placed in the pelvis (upper left), and a pump


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Surgery_Schwartz. three-piece penile implant for the treatment of erectile dysfunction. The prosthesis is composed of two cylinders placed in the penis, a fluid reservoir placed in the pelvis (upper left), and a pump placed within the scrotum (bottom left).erection or priapism, so dose titration must be closely moni-tored. Intraurethral suppositories are composed of alprostadil in the form of a pellet which is then placed in the urethra and mas-saged for absorption. With suppository use, there are concerns about efficacy (only 46–65%) and compliance due to a burning sensation that limits the interest of some users.175,176Third-line treatment of ED is with surgery placement of a penile prosthesis. There are three main types (malleable, two-piece, and three-piece). The malleable device does not inflate/deflate and merely bends in and out of position for intercourse. The two-piece and three-piece devices are inflatable and dif-fer on the presence of a separate fluid reservoir. The two-piece device has the


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Surgery_Schwartz. and merely bends in and out of position for intercourse. The two-piece and three-piece devices are inflatable and dif-fer on the presence of a separate fluid reservoir. The two-piece device has the fluid maintained in the lower half of the penile cylinders, whereas, the three-piece device has a fluid reservoir placed in the pelvis or abdominal wall (Fig. 40-12). Overall, the inflatable prosthesis has high patient and partner satisfaction rates, >92% and >91%, respectively.177PEDIATRIC UROLOGYHypospadiasHypospadias, a condition which may be considered a form of incomplete maturation of the genitalia, is a common abnormal-ity that occurs in 1 out of 250 to 300 newborn boys. The most obvious aspect of hypospadias is a urethral opening that is not at the tip of the glans, and 70% to 80% of affected babies will have a meatus on the mid to distal shaft or proximal glans. A lesser number will have more proximal openings, whether penoscrotal, scrotal, or perineal. In addition to an abnormally


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Surgery_Schwartz. babies will have a meatus on the mid to distal shaft or proximal glans. A lesser number will have more proximal openings, whether penoscrotal, scrotal, or perineal. In addition to an abnormally located meatus, boys usually have deficient ventral foreskin. Associated penile Brunicardi_Ch40_p1759-p1782.indd 177601/03/19 6:35 PM 1777UROLOGYCHAPTER 40curvature, more common in the severe varieties, is referred to as chordee.No diagnostic studies are needed for the majority of boys with hypospadias as there is typically no increased risk of renal or bladder anomalies. Children with associated cryptorchidism, especially with proximal hypospadias and a nonpalpable tes-tis, have an increased risk of a having a coexisting disorder of sexual differentiation (DSD) and need to undergo a thorough evaluation including hormonal studies, karyotype, and pelvic ultrasonography.178Distal hypospadias can usually be repaired in one stage with success rates of greater than 95%. Most would advocate a


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Surgery_Schwartz. evaluation including hormonal studies, karyotype, and pelvic ultrasonography.178Distal hypospadias can usually be repaired in one stage with success rates of greater than 95%. Most would advocate a staged approach to proximal hypospadias with correction of penile curvature at the first stage and formal urethral reconstruc-tion at the second.179 Adults with corrected hypospadias usually have normal sexual function and fertility.Urinary Tract Infections in ChildrenUrinary tract infections (UTI) are common in children, and there is a greater chance of underlying anatomic abnormalities. Children may have conditions such as vesicoureteral reflux, ureteropelvic junction obstruction, ureteroceles, or ectopic ure-ters as causes of these infections. Because of this association, in the past all children with febrile infections would undergo complete evaluations including renal ultrasonography (US) as well as invasive studies such as voiding cystourethrogra-phy (VCUG). However, defining


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Surgery_Schwartz. all children with febrile infections would undergo complete evaluations including renal ultrasonography (US) as well as invasive studies such as voiding cystourethrogra-phy (VCUG). However, defining pyelonephritis as having a positive renal cortical scan, only 30% to 40% of children with febrile UTI will have reflux. Thus the majority of children with febrile infections, and a greater percentage of those with afe-brile infections (cystitis), will be anatomically normal.180 These data have led to a change in imaging guidelines for children with UTI.Guidelines put out by the American Academy of Pediat-rics have markedly changed the way children with infections are evaluated.181 These guidelines suggest that infants less than 2 months of age with febrile infections should undergo both a renal US and VCUG. Children between 2 months and 2 years who have their first documented infection only need have a renal ultrasound performed. A VCUG is only needed if there are abnormalities detected on


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Surgery_Schwartz. US and VCUG. Children between 2 months and 2 years who have their first documented infection only need have a renal ultrasound performed. A VCUG is only needed if there are abnormalities detected on the ultrasound such as hydrone-phrosis, scarring, or other evidence of anatomic abnormality. A VCUG may also be performed if a child has recurrent infections despite empirical treatment. These guidelines do not address children older than 2 years of age but one can assume that simi-lar algorithms of treatment would be appropriate.There is now greater understanding that most children with UTIs, whether pyelonephritis or cystitis, have some ele-ment of bladder and/or bowel dysfunction as the major factor in the development of the infection. Thus, all children with UTIs need to have a thorough assessment of daily bladder and bowel habits. The latter may be difficult to ascertain in younger children, but bowel dysfunction, even subclinical, may be the most important factor in the development


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Surgery_Schwartz. of daily bladder and bowel habits. The latter may be difficult to ascertain in younger children, but bowel dysfunction, even subclinical, may be the most important factor in the development of UTIs. Behavioral therapies such as regular and complete voiding in conjunction with a bowel program should be considered the mainstay of the prevention of infections as opposed to prophylactic antibiotics.Prenatal HydronephrosisAntenatal imaging will show hydronephrosis in nearly 1% of all babies. Though the majority of children will have benign hydro-nephrosis of no clinical significance, it may also be related to vesicoureteral reflux, ureteropelvic junction obstruction, ectopic ureter/ureteroceles, and other upper tract abnormalities. Typi-cally, nothing needs to be done for these children until after birth, at which point a baseline renal ultrasound can be per-formed. Other studies such as a VCUG or Lasix renal scans can then be done depending on the degree of dilation. Diagnosis of upper


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Surgery_Schwartz. after birth, at which point a baseline renal ultrasound can be per-formed. Other studies such as a VCUG or Lasix renal scans can then be done depending on the degree of dilation. Diagnosis of upper tract obstruction is usually based on progressive worsen-ing of dilation or renal function on serial examinations.Special consideration must be given for children with bilateral hydronephrosis or hydronephrosis associated with a solitary kidney, especially if linked to oligohydramnios. Since fetal urine production accounts for much of the amniotic fluid, low levels can be a sign of a severe abnormality of the urinary tract. Reduced amniotic fluid is of great consequence since nor-mal lung development is dependent on normal amniotic fluid volumes and children with oligohydramnios can be born with significant pulmonary insufficiency. Boys with bilateral hydro-nephrosis and low amniotic fluid are at high risk for having posterior urethral valves (PUV). Boys with PUV have as much as a 25% risk


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Surgery_Schwartz. significant pulmonary insufficiency. Boys with bilateral hydro-nephrosis and low amniotic fluid are at high risk for having posterior urethral valves (PUV). Boys with PUV have as much as a 25% risk of developing end stage renal disease at some point in their lives.182 Prenatal intervention such as placement of vesicoamniotic shunts have not been shown to reduce the risk of renal failure.CryptorchidismCryptorchidism or undescended testes (UDT) is a common condition occurring in 3% of full term and 30% of premature babies. Many of these testes will descend spontaneously due to the normal gonadotropin release that occurs in the first few months of life, so the true incidence is roughly 1% of boys. Untreated cryptorchidism will lead to testis damage, and there is evidence that permanent changes may occur by 3 years of age. Ideally, surgical treatment should occur prior to this age. UDT is usually an isolated finding, but it may occur as a part of a systemic condition such as Prader-Willi,


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Surgery_Schwartz. may occur by 3 years of age. Ideally, surgical treatment should occur prior to this age. UDT is usually an isolated finding, but it may occur as a part of a systemic condition such as Prader-Willi, Eagle-Barrett, or other such complex multisystem syndrome. Surgery is the treatment of choice; hormonal treatment has no role.The consequences of untreated cryptorchidism include infertility and malignant degeneration. One study on fertility suggested that men with a history of unilateral cryptorchidism will have no difference in paternity rates compared to normal controls. In contrast, men with bilateral cryptorchidism have up to a 50% rate of infertility.183 There is data to suggest that orchidopexy in the first year of life is associated with better total sperm counts in adulthood.184 With regard to malignancy, untreated UDT has a fivefold increase risk of tumor develop-ment compared to the normal population. However, there is data to suggest that prepubertal orchidopexy is protective


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Surgery_Schwartz. regard to malignancy, untreated UDT has a fivefold increase risk of tumor develop-ment compared to the normal population. However, there is data to suggest that prepubertal orchidopexy is protective and that these boys only have a twofold greater risk.185REFERENCESEntries highlighted in bright blue are key references. 1. Schaeffer A, Matulewicz R, Klumpp D. Infections of the urinary tract. In: Wein AJ, Kavoussi LR, Partin AW, et al, eds. Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016. 2. Polackwich AS, Shoskes DA. Chronic prostatitis/chronic pel-vic pain syndrome: a review of evaluation and therapy. Pros-tate Cancer Prostatic Dis. 2016;19(2):132-138. 3. Link R, Rosen T. Cutaneous diseases of the external genitalia. In: Wein AJ KL, Partin AW, et al, ed. Campbell-Walsh Urology. 11 ed. Philadelphia, Penn: Elsevier; 2016.Brunicardi_Ch40_p1759-p1782.indd 177701/03/19 6:35 PM 1778SPECIFIC CONSIDERATIONSPART II 4. Scales CD, Smith AC, Hanley JM, Saigal CS, Project UDiA.


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Surgery_Schwartz. 11 ed. Philadelphia, Penn: Elsevier; 2016.Brunicardi_Ch40_p1759-p1782.indd 177701/03/19 6:35 PM 1778SPECIFIC CONSIDERATIONSPART II 4. Scales CD, Smith AC, Hanley JM, Saigal CS, Project UDiA. Prevalence of kidney stones in the United States. Eur Urol. 2012;62(1):160-165. 5. Pearle MS, Calhoun EA, Curhan GC, Project UDoA. Uro-logic diseases in America project: urolithiasis. J Urol. 2005;173(3):848-857. 6. Scales CD, Curtis LH, Norris RD, et al. Changing gender prevalence of stone disease. J Urol. 2007;177(3):979-982. 7. Taylor EN, Stampfer MJ, Curhan GC. Diabetes mellitus and the risk of nephrolithiasis. Kidney Int. 2005;68(3):1230-1235. 8. Taylor EN, Stampfer MJ, Curhan GC. Obesity, weight gain, and the risk of kidney stones. JAMA. 2005;293(4):455-462. 9. Heilberg IP. Treatment of patients with uric acid stones. Urolithiasis. 2016;44(1):57-63. 10. Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clini-cal effectiveness protocols for imaging in the management of ureteral calculous


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Surgery_Schwartz. with uric acid stones. Urolithiasis. 2016;44(1):57-63. 10. Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clini-cal effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment. J Urol. 2013;189(4):1203-1213. 11. Poletti PA, Platon A, Rutschmann OT, Schmidlin FR, Iselin CE, Becker CD. Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol. 2007;188(4):927-933. 12. Pearle MS, Goldfarb DS, Assimos DG, et al. Medical management of kidney stones: AUA guideline. J Urol. 2014;192(2):316-324. 13. Hubner WA, Irby P, Stoller ML. Natural history and current concepts for the treatment of small ureteral calculi. Eur Urol. 1993;24(2):172-176. 14. Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient education. J Urol. 1999;162 (3 Pt 1):688-690; discussion 690-681. 15. Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American


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Surgery_Schwartz. observed ureteral calculi: a guide for patient education. J Urol. 1999;162 (3 Pt 1):688-690; discussion 690-681. 15. Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Associa-tion/Endourological Society guideline, PART I. J Urol. 2016;196(4):1153-1160. 16. Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Associa-tion/Endourological Society guideline, PART II. J Urol. 2016;196(4):1161-1169. 17. Lu Z, Dong Z, Ding H, Wang H, Ma B, Wang Z. Tamsulosin for ureteral stones: a systematic review and meta-analysis of a randomized controlled trial. Urol Int. 2012;89(1):107-115. 18. Albala DM, Assimos DG, Clayman RV, et al. Lower pole I: a prospective randomized trial of extracorporeal shock wave lith-otripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. J Urol. 2001;166(6):2072-2080. 19. Ozturk U, Sener NC, Goktug HN, Nalbant I, Gucuk A, Imamoglu MA. Comparison of


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Surgery_Schwartz. and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. J Urol. 2001;166(6):2072-2080. 19. Ozturk U, Sener NC, Goktug HN, Nalbant I, Gucuk A, Imamoglu MA. Comparison of percutaneous nephroli-thotomy, shock wave lithotripsy, and retrograde intrarenal surgery for lower pole renal calculi 10-20 mm. Urol Int. 2013;91(3):345-349. 20. Egan KB. The epidemiology of benign prostatic hyperplasia associated with lower urinary tract symptoms: prevalence and incident rates. Urol Clin North Am. 2016;43(3):289-297. 21. Barry MJ, Fowler FJ, O’Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992;148(5):1549-1557; discussion 1564. 22. O’Leary M. The importance of standardisation and validation of symptom scores and quality of life: the urologist’s point of view. Eur Urol. 1997;32(suppl 2):48-49. 23. McVary KT, Roehrborn CG, Avins AL, et al. Update


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Surgery_Schwartz. of standardisation and validation of symptom scores and quality of life: the urologist’s point of view. Eur Urol. 1997;32(suppl 2):48-49. 23. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185(5):1793-1803. 24. Nickel JC, Herschorn S, Corcos J, et al. Canadian guidelines for the management of benign prostatic hyperplasia. Can J Urol. 2005;12(3):2677-2683. 25. Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign pros-tatic obstruction. Eur Urol. 1999;36(1):1-13. 26. Roehrborn CG, Boyle P, Nickel JC, Hoefner K, Andriole G, Investigators AAaAS. Efficacy and safety of a dual inhibitor of 5-alpha-reductase types 1 and 2 (dutasteride) in men with benign prostatic hyperplasia. Urology. 2002;60(3):434-441. 27. McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin,


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Surgery_Schwartz. types 1 and 2 (dutasteride) in men with benign prostatic hyperplasia. Urology. 2002;60(3):434-441. 27. McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349(25):2387-2398. 28. Roehrborn CG, Barkin J, Siami P, et al. Clinical outcomes after combined therapy with dutasteride plus tamsulo-sin or either monotherapy in men with benign prostatic hyperplasia (BPH) by baseline characteristics: 4-year results from the randomized, double-blind combination of Avodart and Tamsulosin (CombAT) trial. BJU Int. 2011;107(6):946-954. 29. McVary KT, Monnig W, Camps JL, Young JM, Tseng LJ, van den Ende G. Sildenafil citrate improves erectile function and urinary symptoms in men with erectile dysfunction and lower urinary tract symptoms associated with benign pros-tatic hyperplasia: a randomized, double-blind trial. J Urol. 2007;177(3):1071-1077. 30. Wang


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Surgery_Schwartz. symptoms in men with erectile dysfunction and lower urinary tract symptoms associated with benign pros-tatic hyperplasia: a randomized, double-blind trial. J Urol. 2007;177(3):1071-1077. 30. Wang C. Phosphodiesterase-5 inhibitors and benign prostatic hyperplasia. Curr Opin Urol. 2010;20(1):49-54. 31. Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med. 1995;332(2):75-79. 32. Montorsi F, Naspro R, Salonia A, et al. Holmium laser enu-cleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol. 2004;172 (5 pt 1):1926-1929. 33. Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR. A randomized trial comparing holmium


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Surgery_Schwartz. with obstructive benign prostatic hyperplasia. J Urol. 2004;172 (5 pt 1):1926-1929. 33. Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol. 2003;170(4 Pt 1):1270-1274. 34. Elzayat EA, Elhilali MM. Holmium laser enucleation of the prostate (HoLEP): long-term results, reoperation rate, and possible impact of the learning curve. Eur Urol. 2007;52(5):1465-1471. 35. Anger JT, Buckley JC, Santucci RA, Elliott SP, Saigal CS, Urologic Diseases in America P. Trends in stricture management among male Medicare beneficiaries: underuse of urethro-plasty? Urology. 2011;77(2):481-485. 36. Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior ure-thral strictures: etiology and characteristics. Urology. 2005;65(6):1055-1058. 37. Nuss


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Surgery_Schwartz. of urethro-plasty? Urology. 2011;77(2):481-485. 36. Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior ure-thral strictures: etiology and characteristics. Urology. 2005;65(6):1055-1058. 37. Nuss GR, Granieri MA, Zhao LC, Thum DJ, Gonzalez CM. Presenting symptoms of anterior urethral stricture disease: a disease specific, patient reported questionnaire to measure outcomes. J Urol. 2012;187(2):559-562. 38. Bertrand LA, Warren GJ, Voelzke BB, et al. Lower urinary tract pain and anterior urethral stricture disease: prevalence and effects of urethral reconstruction. J Urol. 2015;193(1):184-189. 39. Pal DK, Kumar S, Ghosh B. Direct visual internal urethrotomy: is it a durable treatment option? Urol Ann. 2017;9(1):18-22. 40. Hudak SJ, Atkinson TH, Morey AF. Repeat transurethral manipulation of bulbar urethral strictures is associated with increased stricture complexity and prolonged disease dura-tion. J Urol. 2012;187(5):1691-1695.Brunicardi_Ch40_p1759-p1782.indd 177801/03/19 6:35 PM


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Surgery_Schwartz. bulbar urethral strictures is associated with increased stricture complexity and prolonged disease dura-tion. J Urol. 2012;187(5):1691-1695.Brunicardi_Ch40_p1759-p1782.indd 177801/03/19 6:35 PM 1779UROLOGYCHAPTER 40 41. Pipitone N, Vaglio A, Salvarani C. Retroperitoneal fibrosis. Best Pract Res Clin Rheumatol. 2012;26(4):439-448. 42. Cronin CG, Lohan DG, Blake MA, Roche C, McCarthy P, Murphy JM. Retroperitoneal fibrosis: a review of clini-cal features and imaging findings. AJR Am J Roentgenol. 2008;191(2):423-431. 43. Li KP, Zhu J, Zhang JL, Huang F. Idiopathic retroperitoneal fibrosis (RPF): clinical features of 61 cases and literature review. Clin Rheumatol. 2011;30(5):601-605. 44. Elsamra SE, Leavitt DA, Motato HA, et al. Stenting for malig-nant ureteral obstruction: Tandem, metal or metal-mesh stents. Int J Urol. 2015;22(7):629-636. 45. Lopez-Huertas HL, Polcari AJ, Acosta-Miranda A, Turk TM. Metallic ureteral stents: a cost-effective method of managing benign upper tract


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Surgery_Schwartz. or metal-mesh stents. Int J Urol. 2015;22(7):629-636. 45. Lopez-Huertas HL, Polcari AJ, Acosta-Miranda A, Turk TM. Metallic ureteral stents: a cost-effective method of managing benign upper tract obstruction. J Endourol. 2010;24(3):483-485. 46. Taylor ER, Benson AD, Schwartz BF. Cost analysis of metal-lic ureteral stents with 12 months of follow-up. J Endourol. 2012;26(7):917-921. 47. Baumgarten AS, Hakky TS, Carrion RE, Lockhart JL, Spiess PE. A single-institution experience with metallic ureteral stents: a cost-effective method of managing deficiencies in ureteral drainage. Int Braz J Urol. 2014;40(2):225-231. 48. McAninch JW. Genitourinary trauma. World J Urol. 1999;17(2):65. 49. Breyer BN, McAninch JW, Elliott SP, Master VA. Minimally invasive endovascular techniques to treat acute renal hemor-rhage. J Urol. 2008;179(6):2248-2252; discussion 2253. 50. Hotaling JM, Sorensen MD, Smith TG 3rd, Rivara FP, Wessells H, Voelzke BB. Analysis of diagnostic angiography and


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Surgery_Schwartz. treat acute renal hemor-rhage. J Urol. 2008;179(6):2248-2252; discussion 2253. 50. Hotaling JM, Sorensen MD, Smith TG 3rd, Rivara FP, Wessells H, Voelzke BB. Analysis of diagnostic angiography and angioembolization in the acute management of renal trauma using a national data set. J Urol. 2011;185(4):1316-1320. 51. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989;29(12): 1664-1666. 52. Anselmo da Costa I, Amend B, Stenzl A, Bedke J. Contem-porary management of acute kidney trauma. Journal of Acute Disease. 2016;5(1):29-36. 53. Jansen JO, Inaba K, Resnick S, et al. Selective non-operative management of abdominal gunshot wounds: survey of prac-tise. Injury. 2013;44(5):639-644. 54. Dugi DD 3rd, Morey AF, Gupta A, Nuss GR, Sheu GL, Pruitt JH. American Association for the Surgery of Trauma grade 4 renal injury substratification into grades 4a (low risk) and 4b (high risk). J Urol. 2010;183(2):592-597. 55. McClung CD, Hotaling JM,


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Surgery_Schwartz. JH. American Association for the Surgery of Trauma grade 4 renal injury substratification into grades 4a (low risk) and 4b (high risk). J Urol. 2010;183(2):592-597. 55. McClung CD, Hotaling JM, Wang J, Wessells H, Voelzke BB. Contemporary trends in the immediate surgical management of renal trauma using a national database. J Trauma Acute Care Surg. 2013;75(4):602-606. 56. Atala A, Miller FB, Richardson JD, Bauer B, Harty J, Amin M. Preliminary vascular control for renal trauma. Surg Gyne-col Obstet. 1991;172(5):386-390. 57. Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol. 2003;170(4 Pt 1):1213-1216. 58. Elliott SP, McAninch JW. Ureteral injuries: external and iat-rogenic. Urol Clin North Am. 2006;33(1):55-66, vi. 59. Mauck RJ, Hudak SJ, Terlecki RP, Morey AF. Central role of Boari bladder flap and downward nephropexy in upper ure-teral reconstruction. J Urol. 2011;186(4):1345-1349. 60. Morey AF,


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Surgery_Schwartz. procedures for priapism. J Sex Med. 2013;10(1):180-194. 85. Mackway-Jones K, Teece S. Ice, pins, or sugar to reduce para-phimosis. Emerg Med J. 2004;21(1):77-78.Brunicardi_Ch40_p1759-p1782.indd 177901/03/19 6:35 PM 1780SPECIFIC CONSIDERATIONSPART II 86. Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: point of technique and review of the literature. J Pediatr Urol. 2013;9(1): 104-107. 87. Ubee SS, McGlynn L, Fordham M. Emphysematous pyelone-phritis. BJU Int. 2011;107(9):1474-1478. 88. Lu YC, Hong JH, Chiang BJ, et al. Recommended initial antimicrobial therapy for emphysematous pyelonephritis: 51 cases and 14-year-experience of a tertiary referral center. Medicine (Baltimore). 2016;95(21):e3573. 89. Misgar RA, Mubarik I, Wani AI, Bashir MI, Ramzan M, Laway BA. Emphysematous pyelonephritis: a 10-year experience with 26 cases. Indian J Endocrinol Metab. 2016;20(4):475-480. 90. Lu YC, Chiang BJ, Pong YH, et al. Predictors of failure of


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