경희대학교 의과대학·의학전문대학원

전체 글

(1)

Introduction to Clinical Training

Kyung Hee University Medical Center Department of Urology

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비뇨기과

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Urology

• Male, female urinary tract, male reproductive organs

• Surgical specialty

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Voiding

• Dysuria: Painful urination

• Frequency: Frequent urination

• Urgency: Compelling urge to urination

• Tenesmus: Feeling of incomplete emptying

• Hesitancy: Trouble starting or maintaining a urine stream • Retention: Inability to voluntarily pass urine

• Incontinence [Stress/Urge]: Uncontrolled leakage of urine (Nocturnal enuresis or bed-wetting) • Stream [Small/Divided/Diminished force]

• Dribbling: Terminal release of drops of urine at end of micturition • Nocturia: Nocturnal frequency

• Hematuria [Total/Initial/Terminal] • Urethral discharge

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Patient Presentation #1

• 60/M

입원 전날 술을 마신 이후 요의는 있으나 소변을 보지 못하여 응급

실 내원함 .

(7)

Patient Presentation #2

• 75/F, 2시간 전부터 발생한 급성 복통으로 ER 내원 • 30 년 Hysterectomy

• V/S 150/75-84-20-36.0

• PE: Diffuse Rt abdominal pain and tenderness, CVA Td (-)

• Cr 1.5 mg/dl, CRP 0.99 mg/dl • Pain subsided with analgesics • IMP) AGE

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How to void?

Campbell Walsh Urology 11 edition ch 70 p. 1685

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Urinary retention (ICS)

• Acute Urinary Retention

• A patient is unable pass any urine despite having full bladder, which on examination is painfully distended and readily palpable or percussible.

• Chronic Urinary Retention

• This defined as a generally (but not always) painless and palpable or pe rcussible bladder, where there is a chronic high PVR where the patient experiences slow flow and incomplete bladder emptying. Overflow inco

ntinence can occur. Some individuals with retention present with impai red renal function and/or hydronephrosis.

AUA: PVR greater than 300ml that persisted for at least 6

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Epidemiology

• More common in men

• Male:Female = 13:1

• Men with LUTS: 18-36/1000 men per year • Women: 3/100,000 women per year

• Increases with age

• Age ≥ 70: 10% • Age ≥ 80: 30%

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Common etiologies

• Obstruction

• BPO, prostate or bladder ca, urethral stricture, urolithiasis, clot retention, phimosis, pelvic organ prolapse, constipation

• Neurologic

• Autonomic neuropathy, DM, CVA, spinal cord lesions

• Pharmacologic

• Anti-histamines, anti-cholinergics, anti-psychotics, sympathomimeitcs

• Infection

• Prostatitis, vulvovaginitis, urethritis, herpes simplex

• Trauma

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AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points. Stoffel et al. J Urol. 2017 Jul;198(1):153-160

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Patient Hx and Physical examination

• Past medical history

• Prior history of retention, voiding symptoms • Treatment history of the lower urinary tract • Pelvic trauma

• Medication

• Physical examination

• Lower abdomen distention, tenderness

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Evaluation

• Catheterization

• Decompression and diagnosis

• Laboratory work up

• CBC, Renal function work up, U/A, U/C • PSA

• Imaging studies

• KUB

• Abdomen sonography, transrectal sonography • Retrograde urethrography, cystoscopy

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Evaluation

• Evaluation of voiding status

• Symptom questionnaires (IPSS, ICIQ) • Uroflometry and PVR

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Management

• Bladder decompression

• Symptom relief, preserve detrusor function • Urethral vs Suprapubic

• Urethral stricture, previous prostate surgery, infection • More invasive, perivesical injury

• Long term, less uncomfortable, less risk of stricture and infection

• Indwelling vs intermittent catherization

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Management

• After decompression

• Post-obstructive diuresis

• Increased urinary output, electrolyte imbalance • “Half-saline catch-up”

• Hematuria

• Irrigation

• Hypotension

• Due to rapid decompression and vasodilation? • Not relevant

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Management

• Treating underlying cause after initial decompression

• BPO

• Medical treatment: alpha blockers, 5-alpha reductase inhibitor • Voiding try: Age, detrusor efficiency, amount of retention

• Surgical management: Transurethral resection of prostate (TUR-P), Holmium l aser enucleation of prostate (HoLEP)

• Operability

• Detrusor activity • Postoperative Cx

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Patient Presentation #1

• 20/M

• 1

시간 전 부터 발생한 intermittent flank pain, hematuria

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Urolithiasis

• Highly prevalent disease worldwide

• 7 to 13% in North America, 5-9% in Europe, 1-5% in Asia

• Depends on geographic, climatic, ethnic, dietary, genetic factors • Male > Female (2, 3 times more often)

• Caucasian > Hispanics > Asians > African-American • Uncommon before 20, peak in 40~60

• Climate: Fluid loss to perspiration, sunlight induced increase in Vit D • Obesity, Diabetes, Metabolic syndrome

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Symptoms and Physical Examination

• Pain (Mild ~ Intense, Flank ~ Lower perineum)

• Renal colic

• Hematuria

• Nausea, vomiting, dysuria, urgency, fever

• Renal function deterioration

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Differential diagnosis of flank pain

• Pyelonephritis

• Herpes Zoster

• Biliary colic, cholecystitis

• Intestinal obstruction, diverticulitis, appendicitis

• Aortic aneurysm

• Ectopic pregnancy, ovarian cyst rupture, torsion

• Etc…..

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Workup

• Imaging study

• Non-contrast-enhanced computed tomography: Standard for diagn osis acute flank pain

• Contrast study: Planed stone removal, collecting system evaluation • Sonography: Solitary kidney, fever, doubt regarding Dx of renal colic • KUB, IVP etc

• Laboratory work up

• Cr, Uric acid, calcium, sodium, potassium, CBC, CRP • UA, UC

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Management

• Renal colic management

• NSAIDS, opiates

• Renal decompression or primary ureteroscopic stone removal in anal gesic refractory colic pain

• Sepsis or anuria in obstructed kidney

• Emergency!!

• Decompression (Ureteral stent, or nephrostomy) • Anti-biotics treatment

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Management

• Medical expulsive therapy

• ≤ 5 mm spontaneous expulsion

• Alpha blockers increase stone expulsion rate in distal ureteral stone s > 5 mm

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Stone removal (ureter stones)

• Indications for active removal of ureteral stones are:

• Stones with a low likelihood of spontaneous passage; • Persistent pain despite adequate analgesic medication; • Persistent obstruction;

• Renal insufficiency (renal failure, bilateral obstruction, or single kidn ey)

• SWL (Shock wave lithotripsy)

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Management of ureter stones

• Depends on

• Location • Stone size

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SWL

• Less invasive (outpatient)

• Fewer overall complications compare d with URS or PCNL

• Success dependent on location, ston e size, stone component, pain contro l

• Steinstrasse, remnant stones  Repe ated treatment, pain

• Tissue effect (renal hematoma, dysrh ythmia, liver spleen hematoma, bow el perforation) Infection

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URS (Semi-rigid, flexible)

• More definitive treatment • Larger stones than SWL

• Admission and anesthesia • May need ureteral stenting

• Ureteral injury (stricture, avulsio n), retrograde repulsion into kidne y

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Stone removal (renal stones)

• Indications for the removal of renal stones, include:

• Stone growth

• Stones in high-risk patients for stone formation • Obstruction caused by stones

• Infection

• Symptomatic stones (e.g., pain or hematuria); • Stones > 15 mm

• Stones < 15 mm if observation is not the option of choice; • Patient preference

• Comorbidity

• Social situation of the patient (e.g., profession or travelling); • Choice of treatment

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Management of renal stones

• Depends on • Location • Stone size • Patient preference • Difficult SWL

• Steep infundibular-pelvic angle • Long calyx

• Long skin-to-stone distance • Narrow infundibulum

• Shock wave-resistant stones (calcium ox alate monohydrate, brushite, or cystine).

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RIRS

• Minimal invasive intrarenal surgery

• Learning curve

• Expensive equipment and cost, hi gh maintenance cost

• Increased radiation exposure

• Ureter injury and ureteral stenting • Longer surgery time for larger sto

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PCNL

• Direct route to kidney, large sto

ne removal

• Renal injury, bleeding, difficulty

in choosing percutaneous route

• Increased radiation exposure

• Nephrostomy after surgery

• Mini-perc, tubeless PCNL

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ECIRS

• PCNL + RIRS

• Large, complex urolithiasis

• Prone position

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In conclusion…

• Urinary retention

• Urolithiasis

• Importance of medical history

• DDx and evaluation approach

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