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COMPREHENSIVE SURGICAL LEARNING MATERIAL

Urology & Urogenital Surgery

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SECTION 1: EXAMINATION AND INVESTIGATION OF THE UROGENITAL SYSTEM

History-Taking

• Voiding symptoms: Divided into obstructive (storage) and irritative (voiding) lower urinary tract symptoms (LUTS)
  • Obstructive LUTS: Incomplete emptying, urinary frequency (>every 2 hours), intermittency, weak stream, straining (Valsalva voiding)
  • Irritative LUTS: Urgency, urge incontinence, dysuria, nocturia
• Pain: Flank pain suggests renal/ureteric pathology; suprapubic pain suggests bladder or urethral pathology; perineal pain suggests prostate pathology; scrotal/testicular pain is often acute and requires urgent evaluation
• Haematuria: Timing in the stream (initial, terminal, or throughout)
• Sexual function: Erectile function, libido, ejaculation
• Prior pelvic/urologic surgery, catheterizations, or STIs

Physical Examination

• Inspection: Penile abnormalities (phimosis, hypospadias, skin lesions), scrotal asymmetry
• Palpation: Kidneys (bimanual ballottement), bladder (suprapubic), testicles (consistency, tenderness, masses), epididymis
• Digital Rectal Examination (DRE): Size, consistency, symmetry of the prostate; a hard, nodular prostate raises concern for carcinoma; a smooth, symmetrically enlarged prostate suggests BPH; a tender, boggy prostate indicates prostatitis
• Transillumination: Used to differentiate hydrocele (transilluminates) from solid testicular mass

Investigations

Sources: Campbell Walsh Wein Urology; Sabiston Textbook of Surgery

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SECTION 2: HAEMATURIA

Definition & Classification

• Gross haematuria: Visible blood in urine — always warrants full evaluation
• Microscopic haematuria: ≥3 RBCs/hpf on microscopy (note: dipstick alone is insufficient — it may give false positives with myoglobin or hemoglobin)
• Pseudohaematuria: Red/brown urine without true RBCs — caused by certain foods (beets), medications (rifampicin), or dehydration

Timing in the Urinary Stream

Causes

• Renal cell carcinoma
• Transitional cell carcinoma (urothelial) of the renal pelvis/ureter
• Nephrolithiasis
• IgA nephropathy, glomerulonephritis
• Trauma
• Renal infarction

• Bladder cancer (most common cause of gross haematuria in patients >50 years)
• Bladder stones
• Cystitis (bacterial, radiation-induced, drug-induced)
• BPH
• Urethral stricture/trauma

Risk Factors for Underlying Malignancy

• Age >40
• Male sex
• Smoking history
• Industrial chemical/dye exposure (aromatic amines)
• Chronic cyclophosphamide therapy
• Pelvic irradiation
• Analgesic abuse (phenacetin)

Investigation Algorithm (AUA Guidelines)

1. Exclude: UTI (especially in young women), recent urological manipulation, nephrological disease
2. Urine cytology
3. Cystoscopy + CT urogram for all patients with gross haematuria and for microscopic haematuria with risk factors
4. Urine culture if infection suspected

Source: Campbell Walsh Wein Urology, block 1

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SECTION 3: EXTERNAL HERNIAS AND HYDROCOELES

Inguinal Hernias

Anatomy & Embryology

• Patent processus vaginalis → indirect inguinal hernia or communicating hydrocele
• Incidence of patent processus vaginalis: 80–94% in neonatal autopsy; 20–30% in adults

Types of Inguinal Hernias in Children

• Key: Only indirect hernias and hydroceles enter the scrotum; femoral hernias never do
• Male:Female ratio = 5–10:1; right-sided predominance (3:1) due to later right testicular descent
• Incarceration risk is highest in the first 6 months of life

Clinical Presentation

• Painless reducible bulge in the inguinal region or scrotum
• Bulge may appear with straining, crying, or Valsalva
• Incarcerated hernia: Tender, irreducible bulge + signs of bowel obstruction
• Strangulated hernia: Ischaemic bowel; surgical emergency

Surgery

• Inguinal hernia repair is the most common elective pediatric surgical procedure
• In children: High ligation of the hernia sac (herniotomy) through an inguinal approach
• In adults: Tension-free mesh repair (Lichtenstein technique) is standard
• Laparoscopic approaches allow simultaneous evaluation of the contralateral internal ring

Hydrocoele

Definition

Types

Management

• Neonatal/childhood: Observe until age 2 years for spontaneous resolution
• If persistent after age 2, or adult-onset: Surgical repair (excision of tunica vaginalis or Lord's procedure)
• Adults: Always evaluate for underlying testicular pathology (USS)

Sources: Campbell Walsh Wein Urology block 20; Mulholland & Greenfield's Surgery block 20; Sabiston block 28

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SECTION 4: OBSTRUCTIVE UROPATHY, CATHETERS AND CATHETERIZATION

Obstructive Uropathy

Definition

Causes (by level)

Pathophysiology

• Obstruction → ↑ intraluminal pressure → transmitted to collecting system → hydronephrosis
• Continued glomerular filtration → filtrate reabsorbed by interstitium/lymphatics
• Medullary blood flow compromised → initial tubular dysfunction (impaired concentrating ability) → then ↓ GFR
• Prolonged obstruction → interstitial fibrosis and permanent renal atrophy

Morphology of Hydronephrosis

• Early: Dilation of pelvis and calyces with interstitial inflammation
• Late: Cortical tubular atrophy, blunting of pyramid apices, marked interstitial fibrosis
• End-stage: Kidney reduced to thin-walled cystic structure

Clinical Features

• May be silent (chronic, insidious) or present with flank pain, urinary retention, UTI, haematuria
• Bilateral obstruction → anuria, acute kidney injury
• Chronic incomplete obstruction → polyuria/polydipsia (tubular concentrating defect)

Investigations

• Renal ultrasound: First-line — shows hydronephrosis
• CT KUB: Best for stones; CT urogram for full evaluation
• MAG3 renogram: Gold standard for functional obstruction (UPJ)
• Retrograde pyelography: Most sensitive for ureteral lesions

Management

• Relief of obstruction: Urethral or suprapubic catheter (lower tract), nephrostomy tube or ureteral stent (upper tract)
• Definitive: Treat underlying cause (stone removal, pyeloplasty, stricture repair, TURP)

Urinary Catheterization

Indications

• Acute urinary retention
• Monitoring urine output (critically ill/peri-operative)
• Neurogenic bladder
• Haematuria with clots (catheter irrigation)
• Pre/peri-operative
• Urethral instillation of medication (BCG for bladder cancer)

Types of Urinary Catheters

Complications of Catheterisation

• UTI / catheter-associated UTI (CAUTI) — most common; risk increases with duration
• Urethral trauma / false passage — especially with forceful insertion
• Haematuria — traumatic
• Paraphimosis — if foreskin not reduced after procedure
• Bladder spasm — due to balloon irritation
• Long-term: Urethral stricture, bladder calculi, periurethral abscess

Sources: Robbins Pathology block 10; Comprehensive Clinical Nephrology; Smith & Tanagho's Urology block 5

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SECTION 5: ACUTE SCROTUM

Definition

Differential Diagnosis

Testicular Torsion — Detailed

Mechanism

• Extravaginal torsion: Neonates — twisting of spermatic cord outside tunica vaginalis; usually in utero (prenatal) or within first 30 days (postnatal)
• Intravaginal torsion: Adolescents/adults — bell-clapper deformity (absent normal posterior fixation of tunica vaginalis to scrotal wall); anomaly present bilaterally

Clinical Features

• Sudden, severe unilateral scrotal pain (may radiate to the abdomen)
• Nausea and vomiting
• High-riding testis (cremasteric muscle contraction shortens cord)
• Absent cremasteric reflex
• Horizontal lie of the testis
• Oedema and erythema developing over hours

Diagnosis

• Clinical diagnosis is sufficient — do not delay surgery for imaging if torsion is highly suspected
• Doppler USS: Absence of testicular blood flow confirms torsion (sensitivity ~90%); its absence should not delay surgery
• Radionuclide scan: Most specific but impractical in acute setting

Management — Salvage Rates

• Emergency surgical scrotal exploration via midline raphe incision
• Detorsion → assess viability → orchidopexy (3-point fixation) if viable; orchiectomy if non-viable
• Contralateral orchidopexy always performed in adolescents/adults (bilateral anatomical defect)
• In neonates: Prenatal torsion → urgent orchidopexy of contralateral testis; postnatal torsion → urgent exploration of both testes

Torsion vs Epididymo-orchitis

Sources: Sabiston Textbook of Surgery block 28 & 30; Campbell Walsh Wein Urology block 8; Schwartz's Principles of Surgery

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SECTION 6: CONGENITAL ABNORMALITIES OF THE GENITOURINARY TRACT

Cryptorchidism (Undescended Testis / Vacant Scrotum)

Definition

Classification

• True cryptorchidism: Testis arrested along normal descent path (abdominal, inguinal, prescrotal)
• Ectopic testis: Testis deviated from normal descent path (perineal, femoral, pubopenile)
• Retractile testis: Normal testis that retracts due to hyperactive cremasteric reflex — not a true undescended testis

Incidence

• ~3–4% at birth; ~1% at 1 year (many descend spontaneously in first few months)
• Higher incidence in premature infants

Complications

• Infertility: Undescended testis exposed to higher body temperature → germinal cell damage; bilateral cryptorchidism → azoospermia if untreated
• Malignancy: Risk of testicular cancer increased (especially seminoma); orchidopexy does not reduce malignancy risk but facilitates earlier detection
• Testicular torsion: Higher risk in intra-abdominal testes
• Inguinal hernia: Patent processus vaginalis almost always present

Management

• Surgical treatment (orchidopexy) recommended at 6–18 months of age
• Hormonal therapy (hCG or GnRH) is an option but has limited efficacy and is not widely used
• Orchiectomy for post-pubertal unilateral undescended testis (due to malignancy risk and poor fertility potential)

Posterior Urethral Valves (PUV)

• Most common obstructive urethral lesion in male infants/newborns
• Mucosal folds in the distal prostatic urethra causing variable degrees of obstruction during voiding
• Clinical features: Poor/dribbling urinary stream, recurrent UTI, failure to thrive, bilateral hydronephrosis (palpable abdominal masses)
• Lab findings: Azotemia, impaired concentrating ability, anaemia (if chronic infection)
• Imaging: VCUG (voiding cysturethrogram) — gold standard; shows dilated posterior urethra
• Treatment: Cystoscopic valve ablation; nephrostomy drainage if severe obstruction

Uretero-Pelvic Junction (UPJ) Obstruction

• Most common congenital anomaly of the ureter
• Intrinsic (atretic ureteral segment) or extrinsic (crossing vessel — aberrant renal artery branch)
• Presents with: Flank pain exacerbated by high fluid intake (Dietl's crisis), recurrent UTI, hydronephrosis on imaging
• Gold standard investigation: MAG3 Lasix renogram (t½ >20 min = obstruction)
• Treatment: Dismembered pyeloplasty (Anderson-Hynes) — >90% success; can be done laparoscopically or robotically

Hypospadias

• Opening of the urethral meatus on the ventral surface of the penis (rather than the tip)
• Associated with chordee (penile curvature), foreskin abnormality
• Types: Glanular (50%), penile shaft (30%), penoscrotal/perineal (20%)
• Treatment: Surgical repair before 18 months of age; avoid circumcision (foreskin used for repair)

Vesico-Ureteric Reflux (VUR)

• Retrograde flow of urine from bladder into ureters
• Risk of pyelonephritis and renal scarring
• Graded I–V (Grade V = gross dilation with intrarenal reflux)
• Managed with prophylactic antibiotics and/or endoscopic injection (bulking agents) or ureteral reimplantation

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SECTION 7: BENIGN PROSTATIC HYPERPLASIA (BPH)

Epidemiology

• Affects ~50% of men at age 60 and 90% by the 8th decade
• One of the most common conditions managed by urologists

Pathogenesis

• Stromal and glandular proliferation of the transition zone of the prostate
• Mediated by dihydrotestosterone (DHT): testosterone → DHT via 5α-reductase type 2 in the prostate
• DHT binds nuclear androgen receptors → stimulates stromal proliferation + inhibits epithelial apoptosis
• Oestrogen (↑ relative to falling testosterone with age) acts synergistically with DHT
• DHT is 10× more potent than testosterone; BPH does not occur in castrated males or those with 5α-reductase deficiency

Morphology

• Prostate weight increases 3–5 fold (60–100 g or more)
• Hyperplastic nodules compress the urethra to a slit-like orifice
• Microscopically: Variable proportions of proliferating glands and fibromuscular stroma
• Glands lined by tall columnar cells with peripheral flattened basal cells (contrasting with carcinoma)
• Corpora amylacea (laminated proteinaceous secretory material) in glandular lumina

Symptoms — LUTS

• Storage symptoms: Urgency, frequency, nocturia, urge incontinence
• Voiding symptoms: Weak stream, hesitancy, intermittency, straining
• Post-voiding symptoms: Incomplete emptying, terminal dribbling
• Note: Prostate volume poorly correlates with symptom severity

Complications

• Urinary retention (acute or chronic)
• Bladder hypertrophy → detrusor instability
• Residual urine → recurrent UTI, bladder stones
• Upper tract obstructive uropathy
• Renal failure (bilateral obstruction)

Assessment

• IPSS (International Prostate Symptom Score): Validated symptom questionnaire
• DRE: Smooth, symmetrical, rubbery enlargement
• PSA: Elevated in BPH (~0.1–0.3 ng/mL per gram of benign tissue); must exclude carcinoma
• Post-void residual (PVR) volume
• Urinary flow rate (Qmax <10 mL/s = significant obstruction)
• Renal function if bilateral obstruction suspected

Treatment

Conservative

• Lifestyle modifications: Fluid restriction (evening), avoid caffeine/alcohol, bladder training, double voiding

Medical

Surgical

Sources: Sabiston Textbook of Surgery block 30; Schwartz's Principles of Surgery block 19; Robbins & Kumar Basic Pathology block 6

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SECTION 8: CANCER OF THE PROSTATE

Epidemiology

• Most common cancer in men (in the United States, 3 of the 12 most common cancers are urological)
• Risk increases with age; rare before 50 years
• Higher incidence in Black men; positive family history increases risk

Pathology

• ~95% are adenocarcinoma arising from the peripheral zone (contrasting with BPH, which originates in the transition zone)
• Microscopic features: Malignant glands lack the peripheral basal cell layer seen in BPH
• Graded by the Gleason score: Based on glandular architecture
  • Gleason pattern 1–5 (1 = well-differentiated, 5 = anaplastic)
  • Gleason score = primary + secondary pattern (e.g., 3+4=7)
  • Contemporary reporting uses Grade Groups 1–5 (Grade Group 1 = Gleason ≤6; Grade Group 5 = Gleason 9–10)

Clinical Features

• Early: Often asymptomatic; detected on PSA screening or DRE
• LUTS: If central/transition zone involvement (less common); prostate cancer more typically in peripheral zone
• Advanced/metastatic: Bone pain (osteoblastic metastases to axial skeleton — spine, pelvis), pathological fractures, haematuria, lower limb oedema (lymphatic obstruction), spinal cord compression

PSA

• Glycoprotein produced exclusively by prostatic epithelium
• Normal <4.0 ng/mL; however, PSA is prostate-specific, not cancer-specific
• PSA elevated in: BPH, prostatitis, post-DRE/ejaculation, catheterisation, and cancer
• PSA density (PSA/prostate volume), PSA velocity (rate of rise), and free:total PSA ratio (lower ratio = higher cancer risk) improve specificity

Staging

• T1: Clinically inapparent (found on biopsy or TURP specimen)
• T2: Palpable or visible, confined to prostate
• T3: Extends beyond prostate capsule / seminal vesicle invasion
• T4: Fixed, invades adjacent structures (bladder, rectum)
• N+: Regional lymph node involvement
• M1: Distant metastasis (bone most common → osteoblastic lesions on bone scan)

Diagnosis

1. PSA + DRE
2. TRUS-guided prostate biopsy (12-core systematic biopsy ± targeted biopsy)
3. MRI of the prostate (multiparametric MRI — mpMRI): Identifies suspicious lesions (PI-RADS scoring); increasingly used before biopsy
4. Bone scan: If PSA >20, Gleason ≥8, T3/T4, or symptomatic
5. CT abdomen/pelvis: Lymph node staging in intermediate/high-risk disease

Treatment

Androgen Deprivation Therapy (ADT)

• LHRH agonists (leuprolide, goserelin): Initial testosterone flare → then castration levels
• LHRH antagonists (degarelix): Immediate testosterone suppression, no flare
• Side effects: Hot flushes, erectile dysfunction, osteoporosis, metabolic syndrome, cardiovascular risk

Sources: Sabiston Textbook of Surgery block 30; Robbins & Kumar Basic Pathology block 6; Campbell Walsh Wein Urology

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SECTION 9: URETHRAL STRICTURES

Definition

Anatomy

1. Prostatic urethra
2. Membranous urethra
3. Bulbar urethra (most common site of strictures)
4. Penile urethra
5. Fossa navicularis (distal penile)

Aetiology

Clinical Features

• Weak or split urinary stream
• Incomplete bladder emptying
• Urinary frequency, urgency
• Recurrent UTI
• Urinary retention (severe)

Investigations

• Uroflowmetry: Reduced Qmax; plateau-shaped flow curve
• Retrograde urethrogram (RUG): Gold standard — defines location, length, and severity of stricture
• Voiding cysturethrogram (VCUG): Defines proximal extent
• Cystoscopy + urethroscopy: Direct visualisation

Management

Endoscopic (First-line)

• Urethral dilation: Mechanical stretching; success rate ~30% for a single attempt; drops to ~13% for repeat procedures
• Direct vision internal urethrotomy (DVIU): Incision of stricture under direct vision with a urethrotome; comparable to dilation; success depends on stricture length and location

Surgical Reconstruction (Urethroplasty)

• Urethroplasty has superior long-term success (~85–90%) compared to endoscopic treatment

Sources: Schwartz's Principles of Surgery block 19; Smith & Tanagho's General Urology block 6; Campbell Walsh Wein Urology block 21

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SECTION 10: ERECTILE DYSFUNCTION

Definition

Physiology of Erection

• Complex neurovascular event involving the parasympathetic nervous system (S2–S4), sympathetic NS, and somatic NS
• Sexual stimulation → release of nitric oxide (NO) from nerve endings and endothelium → activates guanylyl cyclase → ↑ cGMP → smooth muscle relaxation → increased arterial inflow to corpus cavernosum → venous occlusion (veno-occlusive mechanism) → erection
• Detumescence: Sympathetic stimulation → ↑ cAMP breakdown → smooth muscle contraction

Aetiology

Evaluation

• Full sexual, medical, and psychosocial history
• Physical exam: Secondary sexual characteristics, genitalia, vascular/neurological exam
• Validated questionnaire: International Index of Erectile Function (IIEF)
• Investigations: Fasting morning testosterone, LH, FSH, prolactin, fasting lipids, HbA1c, fasting glucose
• Specialised: Penile duplex Doppler USS (vascular assessment); biothesiometry (neurological)

Management

Lifestyle

• Weight loss, regular exercise, smoking cessation, alcohol reduction — independently improve erectile function

Medical

Surgical

• Inflatable penile prosthesis (IPP): Gold standard surgical treatment; 3-piece system (paired cylinders + scrotal pump + reservoir); satisfaction rates >90%
• Malleable (semi-rigid) prosthesis: Simpler; lower mechanical failure rate; less natural erection quality
• Penile arterial revascularisation: Inferior epigastric artery pedicle flap; limited to young men with traumatic arterial injury; controversial

Sources: Sabiston Textbook of Surgery block 30; Campbell Walsh Wein Urology

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SECTION 11: CANCERS OF THE KIDNEY

Renal Cell Carcinoma (RCC)

Epidemiology

• Represents 80–85% of all primary renal malignancies
• 2–3% of all adult cancers; ~65,000 cases/year in the USA
• Male:female ratio = 2:1; peak incidence 6th–7th decade
• Risk factors: Smoking (doubles risk), hypertension, obesity, cadmium exposure, acquired polycystic kidney disease (30-fold increased risk in dialysis patients)

Molecular Classification

Clinical Features

• Flank pain
• Gross haematuria
• Palpable abdominal mass

• Polycythaemia (ectopic EPO production)
• Hypercalcaemia (PTHrP or bony metastases)
• Stauffer syndrome (non-metastatic hepatic dysfunction)
• Hypertension (ectopic renin)
• Feminisation/masculinisation (ectopic gonadotropins)
• Amyloidosis

Staging (AJCC/TNM)

Treatment

Systemic therapy for metastatic RCC

• Targeted therapy (1st line): VEGF/VEGFR inhibitors (sunitinib, pazopanib, cabozantinib), mTOR inhibitors (everolimus)
• Immunotherapy: Anti-PD-1/PD-L1 checkpoint inhibitors (nivolumab, pembrolizumab); combination IO therapy now preferred in most patients
• RCC is resistant to cytotoxic chemotherapy

Sources: Robbins & Kumar Basic Pathology block 5; Sabiston Textbook of Surgery block 30; Campbell Walsh Wein Urology

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SECTION 12: UROGENITAL TRAUMA

Background

• 10–15% of all abdominal and pelvic trauma involves the genitourinary system
• Isolated urological injuries are uncommon; associated abdominal/pelvic injuries common
• Initial: Haemodynamic stabilisation → then advanced imaging
• Early urological consultation is essential

Renal Trauma

Mechanism

• Blunt trauma (~80%): MVA, falls, sports; deceleration injuries → intimal tears in renal vasculature
• Penetrating trauma (~20%): Knife/gunshot wounds

Classification (AAST Renal Injury Scale)

Diagnosis

• Gross haematuria with abdominal trauma → renal imaging indicated
• Microscopic haematuria with haemodynamic shock → also image
• CT with IV contrast + delayed phase = gold standard for staging renal injuries

Management

• Grade I–III: Conservative — bed rest, monitoring, serial imaging; angioembolisation for persistent haemorrhage
• Grade IV: Usually non-operative; embolisation for active haemorrhage; stent for urinary extravasation
• Grade V: Surgical exploration; attempt renorrhaphy or partial/total nephrectomy

Ureteral Trauma

• Usually iatrogenic (pelvic surgery, ureteroscopy, gynaecological procedures)
• Presentation: Fever, flank pain, urinary fistula, ileus post-surgery
• Diagnosis: CT urogram; retrograde pyelography (most sensitive)
• Management: Stable → direct surgical repair over ureteral stent; unstable → intraoperative tagging + nephrostomy + delayed repair

Bladder Trauma

• 1–2% of blunt abdominal trauma; 83–95% associated with pelvic fractures
• Gross haematuria present in 75–100% of cases
• Types:
  • Extraperitoneal rupture (most common): Due to pelvic bone fragments; managed conservatively with catheter drainage (2–3 weeks)
  • Intraperitoneal rupture: Dome of bladder (weak point); due to blunt force on full bladder; requires surgical repair
• Diagnosis: Retrograde cystography (CT cystogram) — gold standard; must fill bladder adequately (300–400 mL)

Urethral Trauma

• Posterior urethral injury: Associated with pelvic fractures; disruption at the bulbomembranous junction
  • Presentation: Blood at urethral meatus, perineal bruising, inability to void, "high-riding" prostate on DRE
  • Do not attempt urethral catheterisation before imaging — risk of converting partial to complete tear
  • Management: Primary realignment over a catheter vs suprapubic cystostomy and delayed urethroplasty
• Anterior urethral injury: Bulbar urethra most common; due to straddle injury
  • Urine/blood extravasates within Colles' fascia → butterfly-shaped perineal bruising
  • Management: Suprapubic catheter + delayed urethroplasty

Genital Trauma

• Penile fracture: Rupture of tunica albuginea during erect penile trauma; "cracking sound" + immediate detumescence + haematoma; surgical emergency — immediate surgical repair
• Testicular rupture: From direct blunt trauma; USS-guided; requires surgical exploration and repair (or orchiectomy if non-viable)
• Scrotal avulsion injuries: Manage with debridement and closure; testicles remarkably resistant to infection

Sources: Sabiston Textbook of Surgery block 8; Campbell Walsh Wein Urology block 49

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SECTION 13: TESTICULAR TUMOURS

Epidemiology

• Most common solid malignancy in males aged 15–40 years
• Bimodal distribution: ~2 years of age (yolk sac tumour) and puberty/young adulthood (seminoma/NSGCT)
• Risk factors: Cryptorchidism (most important), testicular atrophy, Klinefelter syndrome, positive family history, contralateral GCT

Classification

Testicular Tumours
├── Germ Cell Tumours (>95%)
│   ├── Seminoma (~50%)
│   └── Non-seminomatous GCT (NSGCT) (~50%)
│       ├── Embryonal carcinoma
│       ├── Yolk sac tumour (endodermal sinus tumour)
│       ├── Choriocarcinoma
│       ├── Teratoma (mature, immature)
│       └── Mixed (most common NSGCT)
└── Non-Germ Cell (Stromal) Tumours (<5%)
    ├── Leydig cell tumour
    └── Sertoli cell tumour

Tumour Markers

Clinical Features

• Painless scrotal mass — most common presentation; often discovered incidentally
• Dull ache or heaviness in the scrotum
• Approximately 10% present with acute pain (haemorrhage into tumour)
• Gynaecomastia (in β-hCG-producing tumours)
• Back/flank pain (retroperitoneal lymph node metastasis)

Diagnosis

1. Scrotal USS with Doppler: First imaging; intratesticular solid hypoechoic mass = cancer until proved otherwise
2. Tumour markers: AFP, β-hCG, LDH (before and after orchiectomy)
3. CT chest/abdomen/pelvis: Staging for retroperitoneal lymphadenopathy and distant metastases
4. Radical inguinal orchiectomy: Both diagnostic AND therapeutic — always inguinal approach (not scrotal, to avoid disturbing lymphatic drainage)

Staging

Seminoma — Treatment

NSGCT — Treatment

• Lymphovascular invasion (LVI): OR 5.2
• Embryonal carcinoma predominance: OR 2.8
• MIB-1 staining >70%: OR 4.7

5-Year Survival

• Stage I: ~99%
• Stage II: ~95%
• Stage III: ~70–80% (with good-risk markers) → ~50% (poor-risk)

Sources: Sabiston Textbook of Surgery block 28 & 30; Campbell Walsh Wein Urology block 42; Schwartz's Principles of Surgery

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SECTION 14: CANCER OF THE BLADDER

Epidemiology

• 9th most common cancer worldwide; predominantly in men (M:F = 3–4:1)
• Peak incidence 50–80 years
• USA: ~90% urothelial carcinoma; ~5% squamous cell carcinoma (SCC); <2% adenocarcinoma

Risk Factors

• Cigarette smoking (strongest risk factor; 2–4× increased risk; accounts for ~50%)
• Aromatic amines / aniline dyes (occupational: rubber, paint, dye industries)
• Cyclophosphamide chemotherapy (haemorrhagic cystitis + long-term malignancy risk)
• Pelvic radiation
• Chronic schistosomiasis (Schistosoma haematobium) → SCC (endemic in East Africa, Middle East)
• Chronic indwelling catheters → SCC
• Phenacetin abuse

Pathology

Urothelial (Transitional Cell) Carcinoma

• FGFR3 mutations, RAS mutations, PI3K activation
• Frequently recur but rarely invade muscle (~20%)

• TP53 and RB gene mutations
• Flat lesion; high-grade; aggressive; progresses to muscle invasion

Morphological grades

• Non-invasive (Ta/Tis): Papillary or flat, within urothelium
• Invasive (T1–T4): Progressive muscular invasion

Clinical Features

• Painless gross haematuria — cardinal symptom (>80%)
• Irritative LUTS (urgency, frequency, dysuria) — especially with CIS
• Advanced: Pelvic pain, ureteric obstruction, lower limb oedema

Investigations

1. Urine cytology: High sensitivity for high-grade/CIS; low sensitivity for low-grade
2. Cystoscopy: Gold standard; white light ± narrow-band imaging (NBI) or photodynamic diagnosis (PDD)
3. TURBT (transurethral resection of bladder tumour): Diagnostic + therapeutic
4. CT urogram: Upper tract evaluation + staging
5. MRI (VIRADS system): Muscle invasion assessment

Staging (TNM)

Treatment

Non-Muscle Invasive Bladder Cancer (NMIBC)

1. TURBT — complete resection; second-look TURBT for high-grade T1 tumours
2. Intravesical therapy:
   • BCG (Bacillus Calmette-Guérin): Gold standard for high-risk NMIBC; immunotherapy; reduces recurrence and progression
   • Mitomycin C (MMC): Chemotherapy; single peri-operative instillation for low/intermediate risk
3. Follow-up cystoscopy: Mandatory surveillance

Muscle-Invasive Bladder Cancer (MIBC)

1. Neoadjuvant cisplatin-based chemotherapy (MVAC or GC) → then surgery (preferred)
2. Radical cystectomy with urinary diversion:
   • Male: Removal of bladder, prostate, seminal vesicles
   • Female: Bladder, uterus, anterior vagina, urethra
   • Urinary diversion: Ileal conduit (urostomy), continent orthotopic neobladder (Studer), continent cutaneous reservoir
3. Bladder-sparing trimodality therapy: TURBT + concurrent chemoradiation (for selected patients)

Metastatic Bladder Cancer

• Platinum-based chemotherapy: MVAC (methotrexate + vinblastine + doxorubicin + cisplatin) or GC (gemcitabine + cisplatin)
• Checkpoint inhibitors: Pembrolizumab, atezolizumab (PD-1/PD-L1)
• Enfortumab vedotin + pembrolizumab: New standard first-line for platinum-ineligible patients

Sources: Robbins & Kumar Basic Pathology block 6; Campbell Walsh Wein Urology block 84; Smith & Tanagho's General Urology

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QUICK REFERENCE SUMMARY TABLE

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