Tumors of Urinary Tract

Presented by

Mugemana Henri Paterne

Ndahura Alli
Benign Renal Tumors

● Renal Cysts
● Renal Cortical Adenoma
● Metaephric Adenoma
● Oncocytoma
● Angiomyolipoma
● Cystic Nephroma and Mixed Epithelial/Stromal Tumor
● Leiomyoma
● Other Benign Renal Tumors …
Benign Renal Tumors
● Renal Cyst

○ Most common benign renal tumor ○ Origin : Sporadic, Acquired or Genetic

■ Up to 10% of the population ■ Genetic renal cyst disease
● Autosomal dominant polycystic kidney disease
○ Risk factors
(ADPKD)
■ Increased age >50
■ Male gender
● Autosomal recessive polycystic kidney disease
■ Hypertension
(ARPKD)
■ Worsening renal function
Benign Renal Tumors
● Renal Cyst

○ Autosomal dominant polycystic kidney disease (ADPKD)

■ Alterations in cilia function (ciliopathies) → Mutation of PKD1 (polycystin-1: on the short arm of
chromosome 16) and PKD2 (polycystin-2: on the long arm of chromosome 4)

■ Diagnosis
● Presentation
○ Presence of at least 2 unilateral or bilateral renal cysts before age 30
○ At least 2 cysts in each kidney between ages 30 and 59
○ 4 cysts in each kidney in patients 60 years or older

■ Tendency to develop hepatic and pancreatic cysts

Benign Renal Tumors
● Renal Cyst
○ Acquired cystic kidney disease (ACKD)
■ Preceded by the development of chronic and end-stage renal disease

● Largely dependent on the length of time on dialysis → 80% of patients develop cysts after 10
years

■ Associated with the development of RCC, with almost 7% developing RCC after 10 years of dialysis

■ Cysts of ACKD arise from the proximal convoluted tubule (as in clear cell RCC)

● Cysts of ADPKD and sporadic renal cyst disease arise from the distal tubule

→ ACKD is associated with a significant increase in malignancy risk and should be followed closely
Benign Renal Tumors
● Renal Cyst

○ The Bosniak classification → A useful tool to estimate malignancy risk and direct therapy

→ Most cysts require no additional follow-up or therapy

Benign Renal Tumors
● Renal Cyst

○ The Bosniak classification → A useful tool to estimate malignancy risk and direct therapy

A, CT scan of a Bosniak I renal cyst. B, CT scan of a Bosniak II renal cyst. Note internal calcification. C, CT
scan of a Bosniak IIF renal cyst. Several thin irregular septations are present within the cyst.

A, CT scan of a Bosniak III renal cyst. Thick, irregular septations are present within the cyst. B, CT scan of a
Bosniak IV renal cyst, with a solid enhancing nodule. C, Bivalved Bosniak IV renal cyst demonstrating a
solid component that proved to be conventional renal cell carcinoma.
Benign Renal Tumors
● Oncocytoma

○ Renal oncocytoma is the most common benign enhancing renal mass

■ Up to 25% of renal masses smaller than 3 cm represent oncocytomas, making them a challenging diagnostic entity in
clinical practice (Shuch et al., 2015)

■ There may be a higher incidence of oncocytoma in older patients with a small renal mass as opposed to younger patients.

○ Renal oncocytoma is a common benign renal tumor that is clinically and radiographically indistinguishable
from RCC.

CT scan of a patient with multiple bilateral oncocytomas.

Benign Renal Tumors
● Oncocytoma

○ Oncocytomas are derived from the distal renal tubules, similar to

chromophobe RCC, and may represent a spectrum of neoplasia as evidenced
in the Birt-Hogg-Dubé genetic syndrome. However, there is no evidence that
oncocytomas undergo malignant transformation in sporadic cases.

■ If oncocytoma is suspected preoperatively, a percutaneous core

biopsy in addition to fine-needle aspiration may reliably provide a
diagnosis when core tissue is available for additional immunostain
panels.

● Recent advancements in immunostain panels have greatly CT scan of a patient with multiple
improved the diagnostic accuracy of pathologic diagnosis bilateral oncocytomas.
from pathologic specimens and even core biopsy
specimens.

○ Active surveillance represents a reasonable treatment strategy that

minimizes risk and increases certainty based on growth kinetics.

A, Bivalved renal oncocytoma demonstrating central scar. B, Oncocytoma with large eosinophilic cells arranged in distinct nests.
Benign Renal Tumors
● Angiomyolipoma

○ 80% occur sporadically mostly in

middle-aged females

○ Angiomyolipoma is the only benign

renal tumor confidently diagnosed on
cross-sectional imaging by the
presence of fat on nonenhanced thin-
cut CT.
Benign Renal Tumors
● Angiomyolipoma

○ Fat-poor angiomyolipoma may still be confused with RCC but if it is suspected preoperatively then
percutaneous biopsy is eminently capable of providing the diagnosis, with positivity for HMB-45 typically
seen with angiomyolipoma.

○ Angiomyolipoma is the most common renal tumor associated with spontaneous hemorrhage, followed by
RCC.

○ Treatment must be individualized, based on the presentation, pregnancy status, tumor size, and renal
function.

■ The treatment of choice in cases of acute hemorrhage is selective renal angioembolization.

■ Treatment options for elective management of larger angiomyolipomas include selective renal
angioembolization and open or minimally invasive partial nephrectomy.
MCQs
1. The most accurate imaging study to characterize a 1. c. Computed tomography (CT) with and without contrast enhancement.
renal mass is:
a. intravenous pyelography. A dedicated (thin-slice) renal CT scan remains the single most important
b. ultrasonography. radiographic image for delineating the nature of a renal mass. In general, any
c. CT with and without contrast enhancement. renal mass that enhances with administration of intravenous contrast
d. magnetic resonance imaging (MRI). material on CT should be considered a renal cell carcinoma (RCC) until
e. renal arteriography. proved otherwise.
2. A hyperdense renal cyst may also be termed 2. b. Bosniak II cyst.
a: a. probable malignancy.
b. Bosniak II cyst. Category II lesions are minimally complicated cysts that are benign but have
c. Bosniak III cyst. some radiologic findings that cause concern. Classic hyperdense renal cysts
d. Bosniak IV cyst. are small (< 3 cm), round, and sharply marginated and do not enhance after
e. probable angiomyolipoma. administration of contrast material.

3. The primary indication for fine-needle aspiration of 3. d. Renal metastasis.

a renal mass is which suspected clinical diagnosis?
Fine-needle aspiration or biopsy is of limited value in the evaluation of renal
a. Renal cell carcinoma
masses. The major problem with this technique is the high incidence of false-
b. Renal oncocytoma negative findings in patients with renal malignancy. The primary indication for
c. Renal adenoma needle aspiration or biopsy of a renal mass occurs when a renal abscess or
d. Renal metastasis infected cyst is suspected or when differentiating RCC from metastatic
e. Renal angiomyolipoma malignancy or renal lymphoma.
MCQs
4. A healthy 79-year-old man is referred after renal biopsy of a e. Observation with follow-up renal imaging in 6 to 12 months.
3.0-cm centrally located renal mass. The biopsy is definitive
for renal oncocytoma. The other kidney is normal, the serum Renal mass biopsy is now performed with increased frequency
creatinine level is 1.0 mg/dL, and there is no evidence of and should be considered in an elderly patient such as this.
metastatic disease. What is the best next step? For those in whom nonextirpative options are being
a. Open radical nephrectomy considered, biopsy can provide important information, such as
b. Laparoscopic nephroureterectomy a definitive nonmalignant diagnosis (as in this example). Given
c. Percutaneous thermal ablation
the benign nature of renal oncocytomas, the best answer is
d. Partial nephrectomy
e. Observation with follow-up renal imaging in 6 to 12 observation with follow-up imaging in 6 to 12 months.
months

c. Positive staining for human melanoma black (HMB)-45.

5. A distinctive finding for renal angiomyolipoma is:
a. positive staining for vimentin. Angiomyolipoma will stain positive for HMB-45 in most cases,
b. a unique cytokeratin expression pattern. and this can be used to confirm the diagnosis in challenging
c. positive staining for human melanoma black-45.
cases. This antigen, which was originally found in association
d. multiple microsomes on electron microscopy.
e. occasional aneuploidy. with melanoma, is expressed by most angiomyolipomas.
MCQs
6. A 45-year-old man with no urinary symptoms has this a. Bosniak II-F lesion—short-interval imaging follow-up
axial contrast-enhanced CT scan. What is the most likely
diagnosis? b. Bosniak IV—cystic RCC

c. Bosniak II cyst

d. Bosniak III cyst

e. Bosniak I cyst

Answer:

b. Bosniak IV—cystic RCC. Notice the enhancing nodules

within the cyst wall with foci of dystrophic calcification
making cystic renal cell carcinoma the most likely
diagnosis.
Malignant Renal Tumors

● Renal Cell Carcinoma

● Wilms tumor
● Sarcomas
● Renal lymphoma and leukemia
● Metastatic tumors
● Carcionoid
● Small cell carcinoma of the kidney
● Primitive neuroectodermal tumor
Malignant Renal Tumors
● Renal Cell Carcinoma (RCC) → an adenocarcinoma of the renal cortex, believed to arise from the PCT

○ Incidence

■ RCC accounts for 2% to 3% of adult malignancies, with a male-to-female predominance of 1.9 to 1

■ RCC typically is diagnosed between 55 and 75 years of age

■ The incidence of RCC has been rising, largely because of incidental detection due on either ultrasonography or CT for
the evaluation of a variety of nonspecific abdominal complaints

○ Risk factors

■ Tobacco exposure (strongest risk factor → relative risk increased by 1.4 to 2.5-fold compared with controls)

■ Hypertension and obesity

■ Approximately 4% to 6% of RCC is familial in origin

Malignant Renal Tumors
● Renal Cell Carcinoma (RCC)

○ Clinical presentation

■ Local symptoms of RCC can include flank pain, gross

hematuria, and palpable abdominal mass; however, this
classic triad of symptoms is now rarely seen.

■ The majority of RCC are detected incidentally; early

detection is more commonly associated with small primary
tumors and localized disease.

■ Paraneoplastic syndromes are seen more commonly with

metastatic disease → many resolve once the malignant
lesion(s) are surgically removed. Hypercalcemia can also be
managed with vigorous hydration and diuresis, or with other
medical approaches.
Malignant Renal Tumors
● Renal Cell Carcinoma (RCC)

○ Pathology

■ Clear cell RCC is the most common subtype (70%–80%) of RCC.

● Origin is the proximal tubule, and hypervascularity and necrosis are frequently present. Typically, these are more
aggressive than the other common subtypes of RCC but also more likely to respond to immunotherapy and other
targeted molecular therapies.

■ Papillary RCC (10%–15% of RCC) is divided into type 1, an indolent form associated with MET mutations and frequently
multifocal, and type 2, which is associated with poorer prognosis.

■ Chromophobe RCC (3%–5% of RCC) is typically an indolent type of RCC that shares some histopathologic features with
benign oncocytomas.

■ Others rare subtypes: Collecting duct (Bellini) and Medullary cell types
Malignant Renal Tumors

● Renal Cell Carcinoma (RCC)

○ Staging and Prognosis of RCC

■ The TNM staging system has

replaced the Robson system
(stage I to IV).

■ Tumor (T) stage is based on

size and extension of the
cancer into renal or extrarenal
structures.
Malignant Renal Tumors

● Renal Cell Carcinoma (RCC)

○ Staging and Prognosis of RCC

■ Pathologic stage is the most

important prognostic factor
for RCC.

■ Invasion of neighboring
organs (T4), involvement of
retroperitoneal lymph nodes
(N1), and the presence of
metastatic disease (M1)
confer a poor outcome for
patients with RCC.
Malignant Renal Tumors

● Renal Cell Carcinoma (RCC)

○ Treatment of Clinical T1 Renal Mass
Malignant Renal Tumors
● Renal Cell Carcinoma (RCC)

○ Treatment of Locally Advanced RCC

■ Involvement of the venous system occurs in 4% to 10% of patients with RCC.
● Venous tumor thrombus should be suspected in patients with a renal tumor who
also have lower extremity edema, isolated right-sided varicocele or one that
does not collapse with recumbency, dilated superficial abdominal veins,
proteinuria, pulmonary embolism, right atrial mass, or nonfunction of the
involved kidney.

■ 45 to 70 % of patients with venous tumor thrombus can be cured with

nephrectomy and thrombectomy.

■ High-quality preoperative imaging (CT or MRI) should be obtained close to the

anticipated surgery to plan for and achieve intraoperative success.

■ Although locally advanced RCC is still primarily a surgical disease, adjuvant

systemic therapy trials should be encouraged and, in select patients,
neoadjuvant approaches may be considered.

■ Local recurrence after partial nephrectomy is more common at sites distant from
the tumor bed and can be managed by repeat partial nephrectomy, completion
nephrectomy, ablation, or surveillance.
Malignant Renal Tumors
● Renal Cell Carcinoma (RCC)
○ Treatment of Advanced RCC

■ Palliative Surgery in Advanced Renal Cell Carcinoma

● In some patients with advanced RCC, cytoreductive

nephrectomy may help alleviate symptoms related to the
primary tumor (e.g., intractable pain, hematuria) or
paraneoplastic manifestations.

○ Resection of metastatic lesions (often in

combination with radiation or systemic therapy) is
sometimes performed for relief of symptoms or to
prevent life-threatening or disabling sequelae.

● Nonsurgical options are often effective in palliating

symptoms associated with RCC; cytoreductive
Malignant Renal Tumors
MCQs
7. A 55-year-old man with hematuria has this contrast enhanced CT scan for
evaluation. The most appropriate therapy is:

a. laparoscopic nephron-sparing surgery.

b. radical nephrectomy.

c. open nephron-sparing surgery.

d. radiofrequency ablation.

e. Cryoablation.

Answer:
→ b. Radical nephrectomy.

The images demonstrate a large mass in the lower pole of the right kidney, with tumor
extension into the right renal vein, extending to the junction of the right renal vein with the
inferior vena cava. The renal vein is enlarged, and tumor vessels are seen within the
thrombus in the renal vein. These findings make radical nephrectomy the best option.
MCQs
8. Which environmental factor is most commonly accepted
as a risk factor for RCC? c. Tobacco use.
→The most generally accepted environmental risk factor
a. Radiation therapy for RCC is tobacco use, although the relative associated
b. Antihypertensive medications risks have been modest, ranging from 1.4 to 2.3 when
c. Tobacco use compared with controls. All forms of tobacco use have been
d. Diuretics implicated, with risk increasing with cumulative dose or
e. High-fat diet packyears. Other well-established risk factors include
obesity and hypertension.

9. In patients undergoing complete surgical excision of an

RCC, the lowest 5-year survival rate is associated with
which factor? e. Lymph node involvement.

a. Perinephric fat involvement →In most studies, the presence of lymph node or distant
b. Microvascular renal invasion metastases has carried a dismal prognosis that is much more
c. Subdiaphragmatic inferior vena caval involvement pronounced than the other distractors.
d. Intra-atrial tumor thrombus
e. Lymph node involvement
Urothelial Tumors of Upper Urinary Tract and Ureter
● Incidence
o Urothelial carcinomas are relatively common: they are the 4 th most common tumor.
Nevertheless, upper urinary tract carcinomas (UTUCs) make up only 5-10% of urothelial
tumors
o The highest incidence in age 70 to 90 years in the Balkan countries (Southeast Europe),
where UTUC represents the 40% of all renal neoplasms.
○ UTUCs are twice as frequent in men than in women.

● Location and Distribution of Tumors

○ Ureteral tumors occur more commonly in the lower than in the upper ureter.
■ About 70% of ureteral tumors occur in the distal ureter
■ 25% in the midureter
■ 5% in the proximal ureter
○ High incidence of metachronous bladder cancer → from 15% to 75% within 5 years of the
development of the upper tract cancer
■ Routine bladder surveillance should be performed.
Urothelial Tumors of Upper Urinary Tract and Ureter

● Risk factors
○ Familial / hereditary UTUCs are linked to Lynch syndrome
○ Tobacco increases the relative risk for UTUC from 2.5 to 7
○ UTUC “amino tumors” were related to occupational exposure to carcinogenic aromatic
amines in rubber, paint, textile industries & agricultural chemicals.
○ Balkan nephropathy is observed as a familial, not inherited, condition related to the dietary
exposure to aristocholic acid (found in some chinese herbs; birthworts, wild ginger)
○ Patients with pelvic and ureteral tumors have been reported to have a history of analgesic
abuse in 22% and 11% of the cases, respectively
○ The excess of inorganic arsenic in drinking water from artesian wells is a significant risk factor
Urothelial Tumors of Upper Urinary Tract and Ureter
● Patterns of Spread
○ Epithelial
■ Both antegrade (most common) and retrograde manners

● Antegrade seeding is thought to be the most likely explanation for the high
incidence of recurrence in patients in whom a ureteral stump is left in situ after
nephrectomy and incomplete ureterectomy .

○ Lymphatic
■ Lymphatic spread to the para-aortic, paracaval, and ipsilateral common iliac and pelvic
lymph nodes
○ Hematogenous
■ The most common sites of hematogenous metastases are liver, lung, and bone
● Although very rare, direct extension into the renal veins and vena cava
Urothelial Tumors of Upper Urinary Tract and Ureter
● Pathology
○ The majority of upper tract tumors are urothelial cancers. Of these, the majority are transitional
cell in origin
■ squamous cell cancers and adenocarcinomas represent a small minority

○ TCC: 90% of upper urinary tract tumors, may present as papillary or sessile lesions.

○ Non-Transitional Cell Carcinoma

■ SCC: 0.7% to 7.0% of upper urinary tract cancers → Frequently a/w chronic
inflammation or infection or with analgesic abuse.
■ Adenocarcinomas: < 1% of all renal pelvic tumors, a/w longterm obstruction,
inflammation, or urinary calculi
■ Micropapillary Variant
■ Other Miscellaneous Tumors
Urothelial Tumors of Upper Urinary Tract and Ureter
● Diagnosis
○ Symptoms and Signs
■ Painless total hematuria (80%)
■ Flank pain (30%), often caused by clots passing down the ureter (‘clot colic’)
■ Asymptomatic when detected, associated with synchronous bladder TCC

○ Investigation
■ Urine cytology and Computerized tomography urography (CTU) → Malignant cells and
a filling defect in the renal pelvis or ureter
● If doubt exists, retrograde ureteropyelography, or flexible ureterorenoscopy with
biopsy (accuracy of grade 90%) are indicated → Some surgeons prefer to have
histological proof of malignancy prior to treatment.

■ Additional staging is obtained by chest CT and, occasionally, isotope bone scan. Staging
uses the TNM (2017) classification
Urothelial Tumors of Upper Urinary Tract and Ureter
● Treatment
○ If staging indicates non-metastatic disease in the presence of a normal contralateral kidney,
the gold standard treatment with curative intent is radical nephroureterectomy (RNU) with
excision of the bladder cuff.
■ A single dose of post-operative mitomycin (MMC) reduces the risk of bladder tumour
recurrence (ODMIT-C Trial, 2011).
■ Follow-up after RNU should continue at least 5y to detect metachronous bladder cancer
(50%) and UUT-TCC (5%)
○ Metastatic disease
■ Systemic combination chemotherapy (platinum-based): for unresectable or
metastatic disease, is a/w a 30% total or partial response at the expense of moderate
toxicity.
■ Palliative surgery or arterial embolization: may be necessary for troublesome
haematuria. Radiotherapy is generally ineffective.
MCQs
10. The majority of ureteral tumors occur in the: e. Distal and midureter.
a. proximal ureter. → Ureteral tumors occur more commonly in the
b. midureter. lower than in the upper ureter. Overall,
c. distal ureter. approximately 70% of ureteral tumors occur in
d. proximal and midureter. the distal ureter, 25% in the midureter, and 5% in
e. distal and mid ureter. the proximal ureter.

d. Hematuria.

→ The most common presenting symptom of

11. The most frequent presenting symptom of
upper tract urothelial tumors is hematuria, either
upper tract urothelial carcinoma is:
gross or microscopic; this occurs in 56% to 98%
a. dysuria.
of patients. Flank pain is the second most
b. flank pain. common symptom, occurring in 30% of patients
c. weight loss. with tumors. Approximately 15% of patients are
d. hematuria. asymptomatic at presentation and are
e. abdominal mass. diagnosed when an incidental lesion is found on
radiologic evaluation
Bladder Cancer
● Incidence
○ found in up to 5% of patients with microscopic hematuria
■ Urothelial carcinomas account for more than 90% of bladder tumors in the United States;
squamous cell carcinoma and adenocarcinoma are rare.
● Risk factors
○ Strong link to smoking, as well as to textile dyes, cyclophosphamide, chronic indwelling
catheters, chronic parasitic infection (Schistosoma haematobium), and radiation exposure.
● Investigation → TCC is categorized as superficial or invasive.
○ Evaluation for TCC requires upper tract imaging via CT/MR urogram, cystoscopy, and urine
cytology
■ In patients unable to undergo CT/MR urogram, renal US combined with bilateral
retrograde pyelograms
○ Metastatic evaluation includes CXR/CT, CT urogram, and liver function tests.
Bladder Cancer
● Investigation → UTUC is categorized as superficial or
invasive.
● Treatment
○ Superficial tumors (CIS, Ta, T1) do not invade the
muscular bladder wall.
■ These tumors can be staged and treated with
transurethral resection (TUR) and possibly intravesical
therapy (bacillus Calmette–Guérin [BCG] or mitomycin
C

■ Between 40% and 80% of superficial tumors recur

within 1 year; thus, diligent follow-up with cystoscopy is
necessary. Recurrent tumors are treated with TUR and
intravesical therapy.
Bladder Cancer
● Investigation → UTUC is categorized as superficial or invasive.
● Treatment
○ The gold standard therapy for muscle-invasive UC (stage ≥ T2) is radical cystectomy,
bilateral pelvic lymph node dissection, and urinary diversion.
■ This involves radical cystoprostatectomy (removal of bladder, prostate, and possibly
urethra) in males and anterior exenteration (removal of bladder, uterus, cervix, and
vaginal anterior wall) in females.

■ Locally advanced or metastatic bladder cancer is treated with chemotherapy.

MCQs
12. A 73-year-old man with a history of Ta bladder cancer is d. Induction of and maintenance with BCG
found to have a 0.5-cm papillary lesion in the prostatic
urethra and undergoes extensive transurethral resection of therapy.
the prostate, revealing high-grade noninvasive disease of
the prostatic urethra without ductal or stromal involvement. For patients with noninvasive prostatic urethral
The next best step is:
cancer, transurethral resection of the prostate
a. perioperative mitomycin C. with BCG therapy is appropriate (Palou et al,
2007). For patients with prostatic ductal
b. surveillance cystoscopy every 3 months.
disease, a complete TURP is warranted, plus
c. mitomycin C therapy. BCG therapy. Although a radical cystectomy
could be performed, a more conservative organ-
d. induction of and maintenance with BCG therapy. sparing treatment is recommended.
e. radical cystectomy.
Prostatic cancer
● Prostate cancer rarely causes symptoms until it becomes locally advanced or metastatic.

● Risk factors for prostate cancer include African-American race, family history of prostate cancer,
advanced age and personal/familial evidence of high risk mutations such as BRCA1/2.

● Screening includes measurement of serum prostate-specific antigen (PSA) →The use of digital
rectal examination (DRE), or other biomarkers, is not useful for primary prostate cancer screening.
○ Abnormalities in PSA should be evaluated by a urologist for consideration of a transrectal
ultrasound (TRUS) with needle biopsy of the prostate.

○ DRE, biomarkers other than PSA, and imaging may inform the decision to undergo prostate
biopsy, but they should not be utilized for initial screening.
Prostatic cancer
● Staging of prostate cancer performed for those men with higher
risk of the disease and consists of an abdomen/pelvis CT/MRI
and a bone scan with aims; 1) prognosis 2) definitive therapy

● Treatment
○ Men with organ-confined prostate cancer
■ Watchful waiting, Active surveillance, Radical
prostatectomy, and Radiation therapy.

○ Recurrent or metastatic disease

■ Androgen Deprivation Therapy (ADT),
medications that inhibit testosterone precursors or
receptors, and/or chemotherapy.
MCQs
13. Identification of patients with high-risk prostate cancer d. Serum PSA, biopsy grade, clinical stage.
is best achieved by:
a. transrectal ultrasonography. Although clinical stage, serum PSA, and Gleason score all
b. serum prostate-specific antigen (PSA). individually predict pathologic stage and prognosis, the
c. digital rectal examination. combination of these three variables increases the accuracy
d. serum PSA, biopsy grade, clinical stage. of this assessment.
e. PSA kinetics

14. A 62-year-old male presents with urinary retention and

perirectal pain. He has had recent low-grade fevers, urinary Answer: c.
urgency, and increasing difficulties voiding until he was
unable to void at all this morning. Digital rectal examination Urinary retention can be caused by any of the above. BPH
reveals a swollen, boggy prostate that is tender on
alone does not present with systemic symptoms like fevers.
examination. What is the likely diagnosis?
The prostatic examination is typically normal with a urinary
a. Benign prostatic hyperplasia (BPH)
tract infection. Prostatic abscess typically presents with high
b. Urinary tract infection
fevers, leukocytosis, and significant pain. A periprostatic fluid
c. Bacterial prostatitis
collection may be palpable. While this clinical scenario does
d. Prostatic abscess
e. Prostate cancer not rule out a prostatic abscess, the most likely diagnosis is
bacterial prostatitis which is treated with empiric antibiotics.
Benign Prostatic Hyperplasia (BPH)
● Signs and symptoms
○ Both obstructive lower urinary tract symptoms (LUTS) viz; weak stream, straining, hesitancy,
incomplete bladder voiding, postvoid dribbling. Irritative symptoms; frequency, urgency and
nocturia.

○ Objective evidence of bladder outlet obstruction (BOO) includes decreased urinary flow rate,
increased postvoid residual, and urinary retention. Bladder stones, hematuria, recurrent UTI,
and renal failure can also occur.
■ Postobstructive diuresis (polyuria and natriuresis) can occur after chronic urinary
obstruction is acutely relieved via catheterization. Rarely, this can last >48 hours and
cause severe electrolyte abnormalities. Patients should be monitored closely with vital
signs, serial laboratory tests, and fluid replacement as needed.
Evaluation
● DRE: to assess prostate size and contour, ● Lab studies: Urinalysis, Urine Culture,
evaluate for nodular texture, asymmetry, or PSA, Electrolytes/ BUN/ SrCr
other findings suggestive for malignancy ● Imaging: Ultrasonography (for
complications), TRUS
● Complications of BOO:
○ Urinary retention
○ Renal insufficiency
○ Recurrent UTIs
○ Gross Hematuria
○ Bladder Calculi
○ CKD
Benign Prostatic Hyperplasia (BPH)
● Treatment
○ Observation/Watchful waiting is best suited for minimally symptomatic patients.

○ Medical treatment includes long-acting selective α-blockers (e.g., tamsulosin) or 5α-

reductase inhibitors (e.g., finasteride). Combination therapy with an α-blocker + 5α-reductase
inhibitor is used for moderate to severe LUTS and those with complications (e.g. Urine
retention)

○ Surgical therapy is indicated in patients who have failed medical therapy or have severe
symptoms.
■ The gold standard for surgical treatment of BPH is TURP
■ Others; TUIP, robotic surgery etc.
MCQs
15. Concerning correlations between baseline parameters,
which statement is TRUE? a. A clinically useful correlation exists between prostate
volume and serum PSA level.
a. A clinically useful correlation exists between
prostate volume and serum prostate-specific antigen
(PSA) level.
In general there is an absence of useful baseline
b. Many studies have shown a significant correlation correlations between subjective and objective
between the transition zone volume and symptom
severity. parameters such as symptoms, frequency, quality of life,
and urinary flow rate measures of obstruction and
c. Correlation of symptoms, bother, interference, and
quality of life are poor. prostate volume. However, symptom, bother, and
interference with quality of life show excellent correlation
d. Urinary flow rate and prostate volume correlate
highly with serum PSA level. with each other, and a clinically useful correlation exists

e. Serum PSA level shows a strong correlation with between total and transition zone prostate volume and
symptom frequency and bother serum PSA in men with BPH.
References
● Campbell-Walsh Urology by Alan Partin, Craig Peters, Louis Kavoussi, Roger
Dmochowski, Alan Wein

● The Washington Manual of Surgery

● Oxford Handbook of Urology by John Reynard, Simon F. Brewster, Suzanne

Biers, Naomi Laura Neal

● Campbell-Walsh Urology 11th Edition Review