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i	Definition of Urology Urology is the medical specialty that deals in the medical and surgical diseases of the kidneys and urinary tract, which include the ureters, bladder and urethra and the male reproductive system and genitalia. Or we also say that the urology deals with diseases and disorders of the male genitourinary tract and the female urinary tract surgical diseases of the adrenal gland are also included. About Urology Urology is one of the the 1st specialities to branch out from the mainstream medical profession. In fact, it is even mentioned in the original greek version of the Hippocratic Oath, wherein specific prohibitions are contained for physicians against cutting "persons labouring under the stone" and to leave it to leave it to those who are practioners of this work. Urological diseases has been described as far back as the ancient Egyptians who did routine suprapubic cyclostomes on patients with urinary retention for bladder stones or enlarged prostates. Urology is one of the few fields that also dabble in pediatric and plastic / reconstructive techniques. One peculiarity of Urology is that in most urologic operations, there is usually a diagnosis. In fact, Urologists take great efforts to have the most accurate working diagnosis prior to operating. This is unlike many operations in General Surgery, wherein they do a significant number of exploratory surgery, wherein one operates not only to cure, but also to find out what the problem is. In fact, urologists are second only to radiologists and Radiotherapists as being the most "radioactive" doctors since we rely strongly on radiographic and ultrasonographic studies. As a result, Urologists are at least as skilled as Radiologists and Ultrasonologists when performing or reading imaging studies of the genito-urinary tract, and these include CAT Scans and MRI's, as well as Radionucleide scans. Urology is also one of the more "expensive" medical specialties. "Expensive" in the sense for the doctor! In all specialties, there are certain equipment or instruments that are absolutely essential to maintain a decent practice, like an ECG machine for Cardiologistists, ophthalmoscopes and slit lamps for Opththalmologists, Doppler Yltrasound machines for Obstetricians, etc. The Urologists needs is a cystoscope and resectoscope set. This can run up to tens of thousands US$. And this doesn't include other instruments that although are not essential, are quite convenient to have like a ureteroscope (flexible and / or rigid), a visual urethrotome, an Otis urethrotome, a cystolithitrite, a nephroscope, the list goes on .... Urology - SIUT Experience Within the past decade, the field of Urology has been on a rapid rise with the development of extracorporeal shock wave lithotripsy, laser and laparoscopic surgery, endourological advances and medical therapy for benign prostatic enlargement. Indeed, Urology is one of the most exciting fields today. The commonest urological disorder in Pakistan is urinary tract stone disease constituting 51% of urological work-load in a tertiary care center. BPH, urological malignancies, paediatric congenital anamolies, urological trauma and chronic renal failure are the other diseases which are treated in different centers in the country. There is one qualified urologist for 1 million population. There are around 50 urological centers with 20 of these attached to teaching hospitals with post-graduate facilities. Management of stone disease has dramatically changed in Pakistan after 1990. Presently there are 30 lithotriptors in the country, most of them are smaller machines and one lithotriptor is for 4.2 million population. Because of high cost of lithotripsy and majority of lithotriptors being in the private sector make overwhelm public sector hospitals e.g. Sindh Institute of Urology and Transplantation (SIUT) where everything is provided free to the patients. Thus the catchment area for three lithotriptors available at SIUT is all over Pakistan and neighbouring country like Afghanistan. Provision of services at SIUT for stone treatment in the form of three lithotriptors, percutaneous nephrolithotomy (PCNL), ureteroscopy and lithoclast had attracted large number of stone patients at this center. More than 11,000 patients were treated at this center during 1990 – 1998 (i.e. post ESWL era). The commonest urological malignancy is bladder tumour in Pakistan followed by prostatic cancer and renal tumours, testicular, adrenal and penile cancer are infrequent. Endoscopic resection of bladder tumours, radical cystectomy, intravesical chemotherapy and radiotherapy for bladder tumours is performed at three centers in the country. Carcinoma of the prostate is treated by radical prostatectomy, TURP, subcapsular orchiectomy and hormone therapy at tertiary center like SIUT. Radiotherapy for carcinoma prostate is done at three centers. Benign prostatic hyperplasia (BPH) constitutes 7.4% work-load at tertiary care center where urology and renal transplantation is actively done, at other teaching hospital it constitutes 20 – 25% of urology. At teaching centers BPH is treated by TURP or open surgery while at district hospitals transvesical prostatectomy is performed by general surgeons. However at SIUT and few other centers, a specialized prostate clinic is run where all modern facilities TURP, TUIP, TUMT, electro vaporization and laser for prostate are available. Paediatrioc urology has not been taken as a special branch of urology in Pakistan but has been started recently and in future it will become a full fledged speciality. Endourology is becoming an increasingly expanding branch for urology in Pakistan. At least 4-5 modern endourology centers are practicing PCNL, TURP, endopyelotomy, optical urethrotomies and endoscopic ablation of posterior urethral valve, bladder neck incision, incision of ureteric strictures and litholopaxy is being performed. This field of urology has benefited and saved many patients from pain of scars and large incisions and large hospital stay of patients. PART - I *Adrenals* *Kidneys* *Calices, Renal Pelvis and Ureter* *Bladder* *Testis* *Scrotum* *Penis and Male Urethra* *Female Urethra* Adrenal Single kidney is capped by an adrenal gland and both organs are enclosed within Gerota's (perirenal) fascia. The right adrenal lies between the liver and vena cava and the left adrenal lies close to the aorta. The adrenal cortex is composed of distinct layers: the outer zona glomerulosa, the middle zona fasciculata and the inner zona reticulairs. *Blood Supply* a) Arterial b) Venous c) Lymphatics Kidneys The kidneys lie along the borders of the psoas muscles and are therefore obliquely placed. The position of the liver cause right kidney to be lower than than left. The kidney are supported by the perirenal fat, the renal vascular pedicle, abdominal muscle tone and the general bulk of the abdominal viscera. The kidneys is seen to be made up of an outer cortex, a central medulla and the internal calices and pelvis. The function unit of the kidney is the nephron, which is composed of a tubule that has both secretory and excretory functions. The secretory portion is contained largely within the cortex and consist of a renal corpuscle and the excretory part of the renal tubule. The excretory portion of this duct lies in the medulla. The excretory portion of the nephron is the collecting tubule which is continuous with the distal end of the ascending limb of the convoluted tubule. It empties its contents through the tip (papilla) of a pyramid into a minor calix. Usually there is one renal artery, a branch of the aorta, that enters the hilum of the kidney between the pelvis, which normally lies posteriorly and the renal vein. It may branch before it reaches the kidney and 2 or more separate arteries may be noted. In duplication of the pelvis and ureter, it is usual for each renal segment to have its own arterial supply. The renal veins are paired with the arteries but any of them will drain the entire kidney if the others are tied off. The renal nerves derived from the renal plexus acompany the renal vessels throught the renal parenchyma. The lymphatics of the kidney drain into the lumber lymph nodes. Calices, Renal Pelvis and Ureter *Calices* The tips of the minor calices are indented by the projecting pyramids. These calices unite to form 2 or 3 major calices, which join to form the renal pelvis. The calices are intrarenal and are intimately related to the renal parenchyma. *Renal Pelvis* The pelvis may be entirely intrarenal or partly intrarenal and partly extrarenal. In feromedially, it tapers to form the ureter. If the pelvis is partly extrarenal, it lies along the lateral border of the psoas muscle and on the quadratus lumborum muscle; the renal vascular pedicle is placed just anterior to it. The left renal pelvis lies at the level of the first or second lumbar vertebra; the right pelvis is little lower. *Ureter* The adult ureter is about 30 cm long varying in direct relation to the height of the individual. It follows a rather smooth S curve. The ureter lies on the psoas muscles, pass medially to the sacroiliac joints and then swing laterally near the ischial spines before passing medially to penetrate the base of the bladder. In females the uterine arteries are closely related to the juxtavesical portion of the ureters. The ureters are covered by the posterior peritoneum, their lowermost portions are closely attached to it, while the juxtavesical portions are embedded in vascular retroperitoneal fat. Bladder The bladder is a hollow muscular organ that serves as a reservoir for urine. In women its posterior wall and dome are invaginated by the uterus. The adult bladder normally has a capacity of 350 - 500 mL. When empty, the adult bladder lies behind the pubic symphysis and is largely a pelvic organ. I infants and children it is situated higher. When it is full, it rises well above the symphysis and can readily be palpated or percussed. When over distended, as in acute or chronic urinary retention, it may cause the lower abdomen to bulge visibly. In males the bladder is related posteriorly to the seminal vesicles, vasa deferentia ureters and rectum and in females the uterus and vagina are interposed between the bladder and the rectum. In both males and females the bladder is related to the posterior surface of the pubic symphasis, and when distended it is in contact with the lower abdominal wall. Testis The average testicle measures about 4 x 3 x 2.5 cm. It has a dense fescial covering called the tunica albuginea testis, which posteriorly is invaginated somewhat into the body of the testis to form the mediastinum testis. This fibrous mediastinum send fibrous septa into the testis, thus separating it into about 250 lobules. The testis is covered anteriorly and laterally by the vaisceral layer of the serous tunica vaginal is which is continuous with the parietal layer that separates the testis from the scortal wall. At the upper pole of the testis is the appendix testis a small pedunculated or sessile body similar in appearance to the appendix of the scrotal wall. The testis is closely attached posteolaterally to the epididymis, particularly at it upper and lower poles. Scrotum Beneath the corrugated skin of the scrotum lies the dartos muscle. Deep to this are the 3 fascial layer derived from the abdominal wall at the time of testicular descent. Beneath these is the parietal layer of the tunica vaginalis. The scrotum is divided into 2 sacs by a septum of connective tissue. The scrotum not only supports the testes but by relaxation or contraction of its muscular layer helps to regular their environmental temperature. Penis and Male Urethra The penis is composed of 2 corpora cavernosa and the corpus spongiosm which contains the urethra whose diameter is 8-10 mm. A covering of skin devoid of fat is loosely applied about these bodies. The prepuce forms a hood over the glans. Beneath the skin of the penis (and scrotum) and extending from the base of the gland to the urogenital diaphragm in Colles' fasica which is continuous with Scarpa's fasica of the lower abdominal wall. The proximal ends of the corpora cavernosa ae attached to the pelvic bones just anterior to the ischial tuberosities. Occupying a depression of their ventral surface in the midline is the corpus spongiosum which is connected proximally to the undersurface of the urogenital diaphragm through which emerges the membranous urethra. The portion of the corpus spongiosum is surrounded by the bulbospongiosus muscle. Its distal end expands to form the glans penis. Female Urethra The adult female urethra is about 4 cm long and 10 mm in diaeter. It is slightly curved and lies beneath the pubic symphasis just anerior to the vagina. The epithelial lining of the female urehtra is squamous in its distal portion and pseudostratified or transitional in the remainder. The submucosa is made up of connective and elastic tissues and spongy venous spaces. Embedded in it are many periurethral glands which are most numerous distally the largest of these are the periurethral glands of Skene, which open on the floor of the urethra just inside he meatus. External to the submucosa is a longitudinal layer of smooth muscle continuous with the inner longitudinal layer of the bladder wall. Surrounding this is a heavy layer of circular smooth muscle fibers extending from the external vesical muscle fibers extending from the external vesical muscular layer. They constitute the true involuntary urethral sphincter. External to this is the circular striated sphincter surrounding the middle third of the urethra this constitutes an intensive element in the musculature of the urethra. PART - II Systemic Manifestations Local and Referred Pain Symptoms of Bladder Outlet Obstruction Incontinence Urinary Stones Systemic Manifestations Symptoms of fever and weight loss should be sought. Renal carcinoma sometimes causes fever. The abscence of fever does not by any means rule out renal infection for it is the rule that chronic pyelonephrits does not cause fever. Weight loss is to be expected in the advanced stages of cancer but it may be noticed also when renal insufficiency due to obstruction or infection supervenes. In children who have "failure to thrive" chronic obstruction, urinary ract infection or both should be suspected. General malaise may be noted with tumours, chronic pyelonephritis or renal failure. The presence of many of these symptoms may be compatible with human immunodeficiency virus. Local and Referred Pain Abnormalities of a urologic organ can also cause pain in any other organ has a sensory nerve supply common to both. Kidney pain Pseudorenal pain Ureteral pain Vesical pain Prostatic pain Testicular pain Epididymal pain Back and leg pain Symptoms of Bladder Outlet Obstruction These are the some important types of the symptoms of Bladder Outlet Obstruction Hesitancy Loss of force and decrease of caliber of the stream Terminal dribbling Urgency Acute urinary retention Chronic urinary retention Interruption of the urinary stream Sense of residual urine Incontinence The important types of incontinence are as follows: True incontinence Stress incontinence Urge incontinence Paradoxic (overflow or false) Urinary Stones Urinary stones have plagued humans since the earliest records of civilization. The etiology of stones remains speculative. If urinary constituents are similar from each kidney and if there is no evidence of obstruction, why don't small stones pass uneventfully down the ureter early in their development? Why do some people form one large stone and others for multiple small calculi? There is much speculation concerning these and other questions. Advances in the surgical treatment of urinary stones have outpaced our understanding of their etiology. As clinicians we are concerned with an expedient diagnosis and efficient treatment. Equally important is a thorough metabolic evaluation directing appropriate medical therapy and lifestyle changes to help reduce recurrent stone disease. ithout such follow-up and medical intervention stone recurrence rates can be as high as 60% within 5 years. uric acid calculi can recur even more frequently. Physicians lood forward to gaining a better understanding of this multifactorial disease process in hopes of developing more effecive prophylaxis. *Introduction* *Urolithiasis affects -* 1 to 5% of the population in industrialized countries *Life time risk -* 20% in men and 5 to 10% in women *Recurrence rate at -* 1 year 10%, 5 years 35% and 10 years 50% 0.9% hospitals admission in USA Cost of treatment = 1.83 billion dollars in 1993 *Modern Theories of Etiology* Super saturation / crystallization theory Inhibitor deficiency theory Matrix initiation Intra nephronic and fixed nucleation Extra nephronic and free particles nucleation *Stone Disease* *Surgically active* if there is evidence of obstruction, pain or associated infection. Surgical intervention of some type is usually needed and the presence of a surgically active stone provides no information on the metabolic activity of the stone formation. *Metabolic activity* is considered to be present when there is evidence of new stone formation, stone growth or the passage of documented gravel within the past year. If previous films are not available or are not of adequate quality to allow the comparison, the stone formation is classified as *indeterminate metabolic activity. If there have been no changes with adequate previous films, the stone formation is classified inactive. Feature of the Patient History Relevant to Urolithiasis* Family history of urolithiasis Age of onset Past history Fluid intake pattern Diet Drug history Clinical course (History of stones, numbers and types of previous surgery, history of infection) *Basal Laboratory Investigations in the Stone-former Patient* Blood chemistry (serum) Calcium, phosphate, uric acid Total proteins and albumin, glucose Creatinine, urea Sodium, potassium, chloride, bicarbonate *24 hour urine (on usual food intake)* Volume, specific gravity Calcium, phosphate, uric acid Oxalate, citrate, magnesium Creatinine, urea, sodium *First-voided morning urine* Specific gravity, pH, crystaluria Urine culture, fasting, calcium to creatinine ratio *X-Ray Density* Only uric acid and matrix (noncrystaline) calculi are truly radiolucent, but uric acid stone occurs in acid urine whereas matrix usually occurs in alkaline urine. Calcium oxalate and calcium phosphate are as dense as bone. Struvite calculi tend to be less dense and are associated with urinary tract infection. Cystine calculi are radiolucent until they reach a size of 4-5 mm, after which they become somewhat dense with a "ground glass" appearance. *Classification of Urolithiasis* Enzyme Disorders Primary hyperoxaluria Type 1 -- glycolic aciduria Type 2 -- glyceric aciduria Xanthinuria 2, 8 - Dihydroxyadeninuria Lesch-Nyhan syndrome (hyperuricosuria) Phosphoribosyl pyrophosphate synthetase superactivity Renal Tubular Syndrome Cystinuria Renal tubular acidosis Hypercalcemic States Hyperparathyroidism Immobilization Others (e.g., hyperocotisonism, hyperthyroidism) Uric Acid Lithiasis Enteric Urolithiasis Idiopathic Calcium Oxalate Urolithiasis Solute excess Hypercalciuria Absorptive Renal Hyperoxaluria Hyperuricosuria Mixed disorders Idiopathic Calcium Oxalate Urolithiasis Hypocitric aciduria Abnormalities of crystal formation modifiers Mixed disorders Edemic Bladder Stome Formation Secondary Urolithiasis Infection Obstruction Structural abnormalities Urinary diversion procedures *Role of Lithotriptor in 'Stone belt'* Patient seek treatment earlier Smaller stones are treated timely Higher throughput of patients in day care setting Positive impact of health awareness programmes Lithotripter for 'prevention' of stone disease *The Need for Medical Therapy* 2/3 of untreated patients will develop new stones within 8 years Newer modalities will have no impact on underlying risk factor Medical therapy can be a cost effective adjunct to surgical management PART - III Extracorporeal Shock Wave Lithotripsy Chemotherapy of Urologic Tumours Urodynamic Studies Extracorporeal Shock Wave Lithoripsy (ESWL) Extracorporeal shock wave lithotripsy has revolutionized the treatment of urinary stones. The concept of using shock waves to fragment stones was noted in the 1950s in Russia. However it was during the investigation of pitting on supersonic aircraft that Dornier, a German aircraft corporation, rediscovered that shock waves originating from passing debris in the atmosphare can crack something that is hard. It was the ingenious application of a model develop in hopes of understanding such shock waves that extracorporeal (outside the body) shock wave lithotripsy (ESWL) emerged. The first clinical application with successful fragmentation of renal calculi was in 1980. The HM-1 (Human Model-1) underwent modifications in 1982 leading to the HM-2 and finally to the widespread application of the HM-3 in Europe, Japan and the United States (with formal FDA approval in December 1984) that transformed the approach to urinary calculi. Since then, more than 350 lithotriptors have been put into use around the world, with millions of patients successfully treated. Since the development of HM-3, Dornier has made modifications of the reflective semiellipsoid disc and computerized the gantry movements to facilitate stone localization. Many other manufacturers have introduced various machines. All require an energy source to creat the shock wave, coupling mechanism to transfer the energy from outside to inside the body and either fluoroscopic or ultrasonic modes, or both, to identify and position the calculi at a focus of converging shock waves. They differ in generated pain and anesthetic or anesthesiologist requirements, consumable components, size, mobility, cost and durability. focal peak pressure, focal dimensions, modular design, possible biliary applications and maximum distance between focus 1 and focus 2. Chemotherapy of Urologic Tumours The use of chemotherapy and biologic therapy in the treatment of malignant tumours of the genitourinary system serves as a paradigm for a multidisciplinary approach to cancer. The careful integration of surgical and chemotherapy treatment has resulted in impressive advances in the management of urologic cancer. By definition, surgical interventions are directed at local management of urologic tumours, whereas chemotherapy and biologic therapy are systemic in nature. While there is no question that there are times in the natural history of enitourinary tumor when only one therapeutic method is required, a multidisciplinary approach is always called for. Urodynamic Studies Urodynamic study is becoming an important part of the evaluation of patient with voiding dysfunctions - dysuria, urinary incontinence, neuropathic disorders, etc. Formerly the examiner simply observed the act of voiding, noting the strength of the urinary stream and drawing inferences about the possibility of obstruction of the bladder outlet. In the 1950s, it became possible to observe the lower urinary tract by fluoroscopy during the act of voiding and in the 1960s, the principles of hydrodynamics were applied to lower urinary tract physiology. The field of urodynamics now has clinical applications in evaluating voidin problems resulting from lower urinary tract disease. The nomenclature of the tests used in urodynamic studies is not yet settled and the meanings of urodynamic terms are sometimes overlapping or confusing. In spite of these difficulties, urodynamics tests are extremely valuable. Symptoms elicited by the history or by physical, endoscopic or even radiographic examination often must be investigated further by urodynamic tests so that therapy can be altered physiology of the lower urinary tract. As is true of many high-technology testing procedures, urodynamic tests have the greatest clinical validity when their interpretation is left to the treating physician, who should their supervise he study or be responsible for correlating all of the findings with personal clinical observations.

Definition of Urology
Urology is the medical specialty that deals in the medical and surgical diseases of the kidneys and urinary tract, which include the ureters, bladder and urethra and the male reproductive system and genitalia.

Or we also say that the urology deals with diseases and disorders of the male genitourinary tract and the female urinary tract surgical diseases of the adrenal gland are also included.

About Urology
Urology is one of the the 1st specialities to branch out from the mainstream medical profession. In fact, it is even mentioned in the original greek version of the Hippocratic Oath, wherein specific prohibitions are contained for physicians against cutting "persons labouring under the stone" and to leave it to leave it to those who are practioners of this work. Urological diseases has been described as far back as the ancient Egyptians who did routine suprapubic cyclostomes on patients with urinary retention for bladder stones or enlarged prostates. Urology is one of the few fields that also dabble in pediatric and plastic / reconstructive techniques. One peculiarity of Urology is that in most urologic operations, there is usually a diagnosis. In fact, Urologists take great efforts to have the most accurate working diagnosis prior to operating. This is unlike many operations in General Surgery, wherein they do a significant number of exploratory surgery, wherein one operates not only to cure, but also to find out what the problem is. In fact, urologists are second only to radiologists and Radiotherapists as being the most "radioactive" doctors since we rely strongly on radiographic and ultrasonographic studies. As a result, Urologists are at least as skilled as Radiologists and Ultrasonologists when performing or reading imaging studies of the genito-urinary tract, and these include CAT Scans and MRI's, as well as Radionucleide scans. Urology is also one of the more "expensive" medical specialties. "Expensive" in the sense for the doctor! In all specialties, there are certain equipment or instruments that are absolutely essential to maintain a decent practice, like an ECG machine for Cardiologistists, ophthalmoscopes and slit lamps for Opththalmologists, Doppler Yltrasound machines for Obstetricians, etc. The Urologists needs is a cystoscope and resectoscope set. This can run up to tens of thousands US$. And this doesn't include other instruments that although are not essential, are quite convenient to have like a ureteroscope (flexible and / or rigid), a visual urethrotome, an Otis urethrotome, a cystolithitrite, a nephroscope, the list goes on ....

Urology - SIUT Experience
Within the past decade, the field of Urology has been on a rapid rise with the development of extracorporeal shock wave lithotripsy, laser and laparoscopic surgery, endourological advances and medical therapy for benign prostatic enlargement. Indeed, Urology is one of the most exciting fields today.

The commonest urological disorder in Pakistan is urinary tract stone disease constituting 51% of urological work-load in a tertiary care center. BPH, urological malignancies, paediatric congenital anamolies, urological trauma and chronic renal failure are the other diseases which are treated in different centers in the country.

There is one qualified urologist for 1 million population. There are around 50 urological centers with 20 of these attached to teaching hospitals with post-graduate facilities.

Management of stone disease has dramatically changed in Pakistan after 1990. Presently there are 30 lithotriptors in the country, most of them are smaller machines and one lithotriptor is for 4.2 million population. Because of high cost of lithotripsy and majority of lithotriptors being in the private sector make overwhelm public sector hospitals e.g. Sindh Institute of Urology and Transplantation (SIUT) where everything is provided free to the patients. Thus the catchment area for three lithotriptors available at SIUT is all over Pakistan and neighbouring country like Afghanistan. Provision of services at SIUT for stone treatment in the form of three lithotriptors, percutaneous nephrolithotomy (PCNL), ureteroscopy and lithoclast had attracted large number of stone patients at this center. More than 11,000 patients were treated at this center during 1990 – 1998 (i.e. post ESWL era).

The commonest urological malignancy is bladder tumour in Pakistan followed by prostatic cancer and renal tumours, testicular, adrenal and penile cancer are infrequent. Endoscopic resection of bladder tumours, radical cystectomy, intravesical chemotherapy and radiotherapy for bladder tumours is performed at three centers in the country. Carcinoma of the prostate is treated by radical prostatectomy, TURP, subcapsular orchiectomy and hormone therapy at tertiary center like SIUT. Radiotherapy for carcinoma prostate is done at three centers.

Benign prostatic hyperplasia (BPH) constitutes 7.4% work-load at tertiary care center where urology and renal transplantation is actively done, at other teaching hospital it constitutes 20 – 25% of urology. At teaching centers BPH is treated by TURP or open surgery while at district hospitals transvesical prostatectomy is performed by general surgeons. However at SIUT and few other centers, a specialized prostate clinic is run where all modern facilities TURP, TUIP, TUMT, electro vaporization and laser for prostate are available.

Paediatrioc urology has not been taken as a special branch of urology in Pakistan but has been started recently and in future it will become a full fledged speciality.

Endourology is becoming an increasingly expanding branch for urology in Pakistan. At least 4-5 modern endourology centers are practicing PCNL, TURP, endopyelotomy, optical urethrotomies and endoscopic ablation of posterior urethral valve, bladder neck incision, incision of ureteric strictures and litholopaxy is being performed. This field of urology has benefited and saved many patients from pain of scars and large incisions and large hospital stay of patients.

PART - I

Adrenals

Kidneys

Calices, Renal Pelvis and Ureter

Bladder

Testis

Scrotum

Penis and Male Urethra

Female Urethra

Adrenal
Single kidney is capped by an adrenal gland and both organs are enclosed within Gerota's (perirenal) fascia. The right adrenal lies between the liver and vena cava and the left adrenal lies close to the aorta. The adrenal cortex is composed of distinct layers: the outer zona glomerulosa, the middle zona fasciculata and the inner zona reticulairs.

Blood Supply

a) Arterial
b) Venous
c) Lymphatics

Kidneys
The kidneys lie along the borders of the psoas muscles and are therefore obliquely placed. The position of the liver cause right kidney to be lower than than left. The kidney are supported by the perirenal fat, the renal vascular pedicle, abdominal muscle tone and the general bulk of the abdominal viscera. The kidneys is seen to be made up of an outer cortex, a central medulla and the internal calices and pelvis. The function unit of the kidney is the nephron, which is composed of a tubule that has both secretory and excretory functions. The secretory portion is contained largely within the cortex and consist of a renal corpuscle and the excretory part of the renal tubule. The excretory portion of this duct lies in the medulla. The excretory portion of the nephron is the collecting tubule which is continuous with the distal end of the ascending limb of the convoluted tubule. It empties its contents through the tip (papilla) of a pyramid into a minor calix.

Usually there is one renal artery, a branch of the aorta, that enters the hilum of the kidney between the pelvis, which normally lies posteriorly and the renal vein. It may branch before it reaches the kidney and 2 or more separate arteries may be noted. In duplication of the pelvis and ureter, it is usual for each renal segment to have its own arterial supply.

The renal veins are paired with the arteries but any of them will drain the entire kidney if the others are tied off.

The renal nerves derived from the renal plexus acompany the renal vessels throught the renal parenchyma. The lymphatics of the kidney drain into the lumber lymph nodes.

Calices, Renal Pelvis and Ureter

Calices
The tips of the minor calices are indented by the projecting pyramids. These calices unite to form 2 or 3 major calices, which join to form the renal pelvis. The calices are intrarenal and are intimately related to the renal parenchyma.

Renal Pelvis
The pelvis may be entirely intrarenal or partly intrarenal and partly extrarenal. In feromedially, it tapers to form the ureter. If the pelvis is partly extrarenal, it lies along the lateral border of the psoas muscle and on the quadratus lumborum muscle; the renal vascular pedicle is placed just anterior to it. The left renal pelvis lies at the level of the first or second lumbar vertebra; the right pelvis is little lower.

Ureter
The adult ureter is about 30 cm long varying in direct relation to the height of the individual. It follows a rather smooth S curve. The ureter lies on the psoas muscles, pass medially to the sacroiliac joints and then swing laterally near the ischial spines before passing medially to penetrate the base of the bladder. In females the uterine arteries are closely related to the juxtavesical portion of the ureters. The ureters are covered by the posterior peritoneum, their lowermost portions are closely attached to it, while the juxtavesical portions are embedded in vascular retroperitoneal fat.

Bladder
The bladder is a hollow muscular organ that serves as a reservoir for urine. In women its posterior wall and dome are invaginated by the uterus. The adult bladder normally has a capacity of 350 - 500 mL. When empty, the adult bladder lies behind the pubic symphysis and is largely a pelvic organ. I infants and children it is situated higher. When it is full, it rises well above the symphysis and can readily be palpated or percussed. When over distended, as in acute or chronic urinary retention, it may cause the lower abdomen to bulge visibly. In males the bladder is related posteriorly to the seminal vesicles, vasa deferentia ureters and rectum and in females the uterus and vagina are interposed between the bladder and the rectum. In both males and females the bladder is related to the posterior surface of the pubic symphasis, and when distended it is in contact with the lower abdominal wall.

Testis
The average testicle measures about 4 x 3 x 2.5 cm. It has a dense fescial covering called the tunica albuginea testis, which posteriorly is invaginated somewhat into the body of the testis to form the mediastinum testis. This fibrous mediastinum send fibrous septa into the testis, thus separating it into about 250 lobules. The testis is covered anteriorly and laterally by the vaisceral layer of the serous tunica vaginal is which is continuous with the parietal layer that separates the testis from the scortal wall. At the upper pole of the testis is the appendix testis a small pedunculated or sessile body similar in appearance to the appendix of the scrotal wall. The testis is closely attached posteolaterally to the epididymis, particularly at it upper and lower poles.

Scrotum
Beneath the corrugated skin of the scrotum lies the dartos muscle. Deep to this are the 3 fascial layer derived from the abdominal wall at the time of testicular descent. Beneath these is the parietal layer of the tunica vaginalis. The scrotum is divided into 2 sacs by a septum of connective tissue. The scrotum not only supports the testes but by relaxation or contraction of its muscular layer helps to regular their environmental temperature.

Penis and Male Urethra
The penis is composed of 2 corpora cavernosa and the corpus spongiosm which contains the urethra whose diameter is 8-10 mm. A covering of skin devoid of fat is loosely applied about these bodies. The prepuce forms a hood over the glans. Beneath the skin of the penis (and scrotum) and extending from the base of the gland to the urogenital diaphragm in Colles' fasica which is continuous with Scarpa's fasica of the lower abdominal wall. The proximal ends of the corpora cavernosa ae attached to the pelvic bones just anterior to the ischial tuberosities. Occupying a depression of their ventral surface in the midline is the corpus spongiosum which is connected proximally to the undersurface of the urogenital diaphragm through which emerges the membranous urethra. The portion of the corpus spongiosum is surrounded by the bulbospongiosus muscle. Its distal end expands to form the glans penis.

Female Urethra
The adult female urethra is about 4 cm long and 10 mm in diaeter. It is slightly curved and lies beneath the pubic symphasis just anerior to the vagina. The epithelial lining of the female urehtra is squamous in its distal portion and pseudostratified or transitional in the remainder. The submucosa is made up of connective and elastic tissues and spongy venous spaces. Embedded in it are many periurethral glands which are most numerous distally the largest of these are the periurethral glands of Skene, which open on the floor of the urethra just inside he meatus. External to the submucosa is a longitudinal layer of smooth muscle continuous with the inner longitudinal layer of the bladder wall. Surrounding this is a heavy layer of circular smooth muscle fibers extending from the external vesical muscle fibers extending from the external vesical muscular layer. They constitute the true involuntary urethral sphincter. External to this is the circular striated sphincter surrounding the middle third of the urethra this constitutes an intensive element in the musculature of the urethra.

PART - II

Systemic Manifestations

Local and Referred Pain

Symptoms of Bladder Outlet Obstruction

Incontinence

Urinary Stones

Systemic Manifestations
Symptoms of fever and weight loss should be sought. Renal carcinoma sometimes causes fever. The abscence of fever does not by any means rule out renal infection for it is the rule that chronic pyelonephrits does not cause fever. Weight loss is to be expected in the advanced stages of cancer but it may be noticed also when renal insufficiency due to obstruction or infection supervenes. In children who have "failure to thrive" chronic obstruction, urinary ract infection or both should be suspected. General malaise may be noted with tumours, chronic pyelonephritis or renal failure. The presence of many of these symptoms may be compatible with human immunodeficiency virus.

Local and Referred Pain
Abnormalities of a urologic organ can also cause pain in any other organ has a sensory nerve supply common to both.

Kidney pain

Pseudorenal pain

Ureteral pain

Vesical pain

Prostatic pain

Testicular pain

Epididymal pain

Back and leg pain

Symptoms of Bladder Outlet Obstruction

These are the some important types of the symptoms of Bladder Outlet Obstruction

Hesitancy

Loss of force and decrease of caliber of the stream

Terminal dribbling

Urgency

Acute urinary retention

Chronic urinary retention

Interruption of the urinary stream

Sense of residual urine

Incontinence

The important types of incontinence are as follows:

True incontinence

Stress incontinence

Urge incontinence

Paradoxic (overflow or false)

Urinary Stones
Urinary stones have plagued humans since the earliest records of civilization. The etiology of stones remains speculative. If urinary constituents are similar from each kidney and if there is no evidence of obstruction, why don't small stones pass uneventfully down the ureter early in their development? Why do some people form one large stone and others for multiple small calculi? There is much speculation concerning these and other questions.

Advances in the surgical treatment of urinary stones have outpaced our understanding of their etiology. As clinicians we are concerned with an expedient diagnosis and efficient treatment. Equally important is a thorough metabolic evaluation directing appropriate medical therapy and lifestyle changes to help reduce recurrent stone disease. ithout such follow-up and medical intervention stone recurrence rates can be as high as 60% within 5 years. uric acid calculi can recur even more frequently. Physicians lood forward to gaining a better understanding of this multifactorial disease process in hopes of developing more effecive prophylaxis.

Introduction

Urolithiasis affects - 1 to 5% of the population in industrialized countries
Life time risk - 20% in men and 5 to 10% in women
Recurrence rate at - 1 year 10%, 5 years 35% and 10 years 50%
0.9% hospitals admission in USA
Cost of treatment = 1.83 billion dollars in 1993

Modern Theories of Etiology

Super saturation / crystallization theory
Inhibitor deficiency theory
Matrix initiation
Intra nephronic and fixed nucleation
Extra nephronic and free particles nucleation

Stone Disease

Surgically active if there is evidence of obstruction, pain or associated infection. Surgical intervention of some type is usually needed and the presence of a surgically active stone provides no information on the metabolic activity of the stone formation.
Metabolic activity is considered to be present when there is evidence of new stone formation, stone growth or the passage of documented gravel within the past year.
If previous films are not available or are not of adequate quality to allow the comparison, the stone formation is classified as indeterminate metabolic activity.
If there have been no changes with adequate previous films, the stone formation is classified inactive.

Feature of the Patient History Relevant to Urolithiasis

Family history of urolithiasis
Age of onset
Past history
Fluid intake pattern
Diet
Drug history
Clinical course (History of stones, numbers and types of previous surgery, history of infection)

Basal Laboratory Investigations in the Stone-former Patient

Blood chemistry (serum)

Calcium, phosphate, uric acid
Total proteins and albumin, glucose
Creatinine, urea
Sodium, potassium, chloride, bicarbonate

24 hour urine (on usual food intake)

Volume, specific gravity
Calcium, phosphate, uric acid
Oxalate, citrate, magnesium
Creatinine, urea, sodium

First-voided morning urine

Specific gravity, pH, crystaluria
Urine culture, fasting, calcium to creatinine ratio

X-Ray Density

Only uric acid and matrix (noncrystaline) calculi are truly radiolucent, but uric acid stone occurs in acid urine whereas matrix usually occurs in alkaline urine.
Calcium oxalate and calcium phosphate are as dense as bone.
Struvite calculi tend to be less dense and are associated with urinary tract infection.
Cystine calculi are radiolucent until they reach a size of 4-5 mm, after which they become somewhat dense with a "ground glass" appearance.

Classification of Urolithiasis

Enzyme Disorders
     Primary hyperoxaluria
     Type 1 -- glycolic aciduria
     Type 2 -- glyceric aciduria
     Xanthinuria
     2, 8 - Dihydroxyadeninuria
     Lesch-Nyhan syndrome (hyperuricosuria)
     Phosphoribosyl pyrophosphate synthetase superactivity
Renal Tubular Syndrome
Cystinuria
Renal tubular acidosis
Hypercalcemic States
      Hyperparathyroidism
      Immobilization
      Others (e.g., hyperocotisonism, hyperthyroidism)
Uric Acid Lithiasis
Enteric Urolithiasis
Idiopathic Calcium Oxalate Urolithiasis
Solute excess
      Hypercalciuria
           Absorptive
           Renal
      Hyperoxaluria
      Hyperuricosuria
      Mixed disorders
Idiopathic Calcium Oxalate Urolithiasis
       Hypocitric aciduria
       Abnormalities of crystal formation modifiers
       Mixed disorders
Edemic Bladder Stome Formation
Secondary Urolithiasis
       Infection
       Obstruction
       Structural abnormalities
       Urinary diversion procedures

Role of Lithotriptor in 'Stone belt'

Patient seek treatment earlier
Smaller stones are treated timely
Higher throughput of patients in day care setting
Positive impact of health awareness programmes
Lithotripter for 'prevention' of stone disease

The Need for Medical Therapy

2/3 of untreated patients will develop new stones within 8 years
Newer modalities will have no impact on underlying risk factor
Medical therapy can be a cost effective adjunct to surgical management

PART - III

Extracorporeal Shock Wave Lithotripsy

Chemotherapy of Urologic Tumours

Urodynamic Studies

Extracorporeal Shock Wave Lithoripsy (ESWL)
Extracorporeal shock wave lithotripsy has revolutionized the treatment of urinary stones. The concept of using shock waves to fragment stones was noted in the 1950s in Russia. However it was during the investigation of pitting on supersonic aircraft that Dornier, a German aircraft corporation, rediscovered that shock waves originating from passing debris in the atmosphare can crack something that is hard. It was the ingenious application of a model develop in hopes of understanding such shock waves that extracorporeal (outside the body) shock wave lithotripsy (ESWL) emerged. The first clinical application with successful fragmentation of renal calculi was in 1980. The HM-1 (Human Model-1) underwent modifications in 1982 leading to the HM-2 and finally to the widespread application of the HM-3 in Europe, Japan and the United States (with formal FDA approval in December 1984) that transformed the approach to urinary calculi. Since then, more than 350 lithotriptors have been put into use around the world, with millions of patients successfully treated.

Since the development of HM-3, Dornier has made modifications of the reflective semiellipsoid disc and computerized the gantry movements to facilitate stone localization. Many other manufacturers have introduced various machines. All require an energy source to creat the shock wave, coupling mechanism to transfer the energy from outside to inside the body and either fluoroscopic or ultrasonic modes, or both, to identify and position the calculi at a focus of converging shock waves. They differ in generated pain and anesthetic or anesthesiologist requirements, consumable components, size, mobility, cost and durability. focal peak pressure, focal dimensions, modular design, possible biliary applications and maximum distance between focus 1 and focus 2.

Chemotherapy of Urologic Tumours
The use of chemotherapy and biologic therapy in the treatment of malignant tumours of the genitourinary system serves as a paradigm for a multidisciplinary approach to cancer. The careful integration of surgical and chemotherapy treatment has resulted in impressive advances in the management of urologic cancer. By definition, surgical interventions are directed at local management of urologic tumours, whereas chemotherapy and biologic therapy are systemic in nature. While there is no question that there are times in the natural history of enitourinary tumor when only one therapeutic method is required, a multidisciplinary approach is always called for.

Urodynamic Studies
Urodynamic study is becoming an important part of the evaluation of patient with voiding dysfunctions - dysuria, urinary incontinence, neuropathic disorders, etc. Formerly the examiner simply observed the act of voiding, noting the strength of the urinary stream and drawing inferences about the possibility of obstruction of the bladder outlet. In the 1950s, it became possible to observe the lower urinary tract by fluoroscopy during the act of voiding and in the 1960s, the principles of hydrodynamics were applied to lower urinary tract physiology. The field of urodynamics now has clinical applications in evaluating voidin problems resulting from lower urinary tract disease.

The nomenclature of the tests used in urodynamic studies is not yet settled and the meanings of urodynamic terms are sometimes overlapping or confusing. In spite of these difficulties, urodynamics tests are extremely valuable. Symptoms elicited by the history or by physical, endoscopic or even radiographic examination often must be investigated further by urodynamic tests so that therapy can be altered physiology of the lower urinary tract.

As is true of many high-technology testing procedures, urodynamic tests have the greatest clinical validity when their interpretation is left to the treating physician, who should their supervise he study or be responsible for correlating all of the findings with personal clinical observations.