• superiorly, renal fascia is continuous with fascia
on the inf surface of diaphragm
• What lies posterior to kidneys:
• quadratus lumborum muscle
• iliohypogastric and iliinguinal nerves
• subcostal n
• psoas major
• diaphragm
• what lies ant to kidneys
• right side: hepatic flexure, ascend colon,
duodenum
• left side: descend colon, pancreas, jejunum,
spleen
• Renal A.→ ant and posterior braches→
segmental arteries → interlobar arteries →
interlobular arteries → afferent arteriole →
glomerulus → efferent arteriole
• at the hilum, renal vein is anterior to renal artery
and both of them ant to renal pelvis
• renal arteries come off the abdom aorta at the
level of sup. mesenteric artery
• but variants are 25% of all cases
TURBT: trans urethral resection of bladder
tumor
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intravesical immunotherapy ve intravesical
chemotherapy yapılabilir
intravesical immunotherapy → BCG ile
intravesical chemotherapy → Mitomycin C and
…
Urinary Tract Urothelial Carcinoma “UTUC”
UTUC may arise from lower tract (urethra and
bladder) or upper tract (pylorocalices and ureters)
Bladder tumors account for 90-95% of Urothelial
Tumors
Upper UTUCs are rare 5-10%
pyelocaliceal tumors are twice as common as
urethral tumors
following tx for bladder ca, recurrence rate is
25-45
at dx, 60% of UTUCs are invasive at diagnosis
compared with 15–25% of bladder tumours
UTUC peak age 70-90
UTUC three times more common in men
HNPCC linked to UTUCs (10-20% of UTUCs)
non-urothelial histology among UTUCs are rare
Squamous cell ca of urinary tract is often
assumed to be assoc. w. chronic inf such arising
from urolithiasis
T2 when tumor invades muscularis
Urine cytologic examination is highly sensitive
and specific for the detection of high-grade
urothelial carcinoma
CTU (CT Urography) is an excretory urography
in which the MDCT is used for imaging of the
urinary tract. It is indicated in the workup of
hematuria, kidney stones, renal masses, renal
colic, and urothelial tumors.
Ureteroscopic biopsies can determine tumor
grade in 90% of cases though stage assessment is
difficult
flexible ureteroscopy is esp. useful in dx
uncertainty. Combining uterescopic biopsy grade,
imaging evidence of hydronephrosis, urinary
cytology may help decision making bt. Radical
Nephroureterectomy and kidney sparing therapy.
However, recent studies suggest a higher rate of
 intravesical recurrence in patients (particularly in
case of renal pelvic tumour) who underwent URS
before RNU
Gender is no longer considered an independent
prognostic factor influencing UTUC mortality
tumor location → ureteral and/or multifocal
tumours seem to have a WORSE prognosis than
renal pelvic tumours
Of the four discussed imaging techniques, CTU
and MRU are the main tests used to define local
tumour stage, nodal invasion and presence of
metastasis, as retrograde urography and
excretory urography cannot detect these features
The role of cytology includes detecting lesions
that are not seen by imaging or not visually
recognized during cystoscopy or
ureterorenoscopy
TRUS — trans rectal ultrasound
mpMRI — multiparametric mri with T2
weighted images
PCA-3 Test: Not everyone is a candidate for this
test, but it may be helpful when there are mixed
results from traditional PSA tests, such as:
• high PSA level but negative biopsy
• having cancer despite low PSA levels
• high PSA level and also having prostatitis
The good thing about this test is that PCA3 levels
are not affected by other conditions that can raise a
PSA level, such as prostatitis, enlarged prostate, or
UTI
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Irritative urinary symptoms include the
following:
*Frequency—urinating much more often than
normal.
*Nocturia—awakening from sleep to urinate.
*Urgency—the sudden and strong desire to
urinate.
*Precipitancy—the need to get to the toilet in
a hurry to prevent leakage.
*Urgency Incontinence—the sudden and
strong desire to urinate with an inability to
get to the toilet in time to prevent an
accident.
Underlying causes of irritative voiding
symptoms include:
*Irritative focus within the bladder—bladder
infection, bladder stone or foreign body,
bladder tumor, stone in lower ureter.
*Urinary tract obstruction—prostate
enlargement, obstructive cystocele.
*Sensory instability—a small capacity bladder
that is excessively sensitive to filling.
*Bladder instability—a bladder that contracts
(squeezes) at inappropriate times and without
its owner’s permission.
*Bladder hyper-reflexia—a bladder that
contracts at inappropriate times as a result of
disease of the brain or spinal cord, including
trauma, strokes, multiple sclerosis, etc.
*Poor bladder compliance—a bladder with a
rigid and poorly elastic wall that cannot
stretch appropriately as the bladder fills.

Obstructive urinary symptoms include:
*Hesitancy—a stream that is very slow to
start.
*Weak stream—a stream that lacks force or
pressure.
*Small caliber stream—a narrow and thinned
stream.
*Intermittency—a stream that tends to start
and stop.
*Straining—the need to use the abdominal
muscles to generate a stream.
*Prolonged emptying time
*Incomplete emptying—the sensation of urine
remaining in the bladder after completing
urination.
Underlying causes of obstructive voiding
symptoms include:
*Benign prostate gland enlargement
*Prostate cancer
*Excess muscle tone within the prostate and
bladder neck
*Urethral stricture—a scar within the channel
that conducts urine from the bladder.
*Poorly contractile bladder—a weak bladder
muscle that cannot generate pressure to
satisfactorily empty the bladder.
*Urinary tract infection
Blddar ca → Eighty percent of urothelial
carcinomas will contain some mixed
differentiation, most commonly squamous cell.
Small cell carcinoma of the bladder should be
treated as metastatic disease with institution of
chemotherapy followed by either radiation
therapy or surgery.
KUB “kidney-ureter-bladder (KUB) radiography”
Ureteral access sheaths allow repeated access to
the intrarenal collecting system without having
to replace the working guidewire with each
passage of the endoscope
Most protocols
include follow-up (cystoscopy+cytology) every 3
months for 18 to 24 months after the initial diagnosis,
then every 6 months for the following 2 years,
then annually, resetting the clock with each newly
identified tumor (Fitzpatrick, 1993).
bladder ca’da TUR dan önce 3 ü varsa baseline
CT: high grade, multiple,

The diagnosis of CIS can NOT be made with

imaging methods (CT urography, IVU or US)
guideline 27. sayfa mavi tablodan okumaya
devam

BEP (bleomycin, etoposide, cisplatin)

“RPLND” retroperitoneal lymph node dissection
Painless gross hematuria occurs in 85% of
patients with bladder cancer and requires a
complete evaluation that includes cystoscopy,
urine cytology, CT scan, and a PSA blood test.
There are various urine markers that can be used
to evaluate in the hope of noninvasively
detecting bladder cancer. To date, none of these
markers has a high enough sensitivity or
specificity to replace office cystoscopy.
Smoking cessation will decrease the risk of
eventual urothelial cancer formation in a linear
fashion. After 15 years of not smoking, the risk of
cancer formation is the same as for someone who
never smoked. (***for bladder ca)

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