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• superiorly, renal fascia is continuous with fascia intravesical immunotherapy ve intravesical

on the inf surface of diaphragm chemotherapy yapılabilir


• What lies posterior to kidneys: intravesical immunotherapy → BCG ile
• quadratus lumborum muscle intravesical chemotherapy → Mitomycin C and
• iliohypogastric and iliinguinal nerves …
• subcostal n Urinary Tract Urothelial Carcinoma “UTUC”
• psoas major UTUC may arise from lower tract (urethra and
• diaphragm bladder) or upper tract (pylorocalices and ureters)
• what lies ant to kidneys Bladder tumors account for 90-95% of Urothelial
• right side: hepatic flexure, ascend colon, Tumors
duodenum Upper UTUCs are rare 5-10%
• left side: descend colon, pancreas, jejunum, pyelocaliceal tumors are twice as common as
spleen urethral tumors
• Renal A.→ ant and posterior braches→ following tx for bladder ca, recurrence rate is
segmental arteries → interlobar arteries → 25-45
interlobular arteries → afferent arteriole → at dx, 60% of UTUCs are invasive at diagnosis
glomerulus → efferent arteriole compared with 15–25% of bladder tumours
• at the hilum, renal vein is anterior to renal artery UTUC peak age 70-90
and both of them ant to renal pelvis UTUC three times more common in men
• renal arteries come off the abdom aorta at the HNPCC linked to UTUCs (10-20% of UTUCs)
level of sup. mesenteric artery non-urothelial histology among UTUCs are rare
• but variants are 25% of all cases
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
TURBT: trans urethral resection of bladder cytology may help decision making bt. Radical
tumor Nephroureterectomy and kidney sparing therapy.
However, recent studies suggest a higher rate of

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intravesical recurrence in patients (particularly in Irritative urinary symptoms include the
case of renal pelvic tumour) who underwent URS following:
*Frequency—urinating much more often than
before RNU normal.
Gender is no longer considered an independent *Nocturia—awakening from sleep to urinate.
prognostic factor influencing UTUC mortality *Urgency—the sudden and strong desire to
urinate.
tumor location → ureteral and/or multifocal
*Precipitancy—the need to get to the toilet in
tumours seem to have a WORSE prognosis than a hurry to prevent leakage.
renal pelvic tumours *Urgency Incontinence—the sudden and
strong desire to urinate with an inability to
Of the four discussed imaging techniques, CTU
get to the toilet in time to prevent an
and MRU are the main tests used to define local accident.
tumour stage, nodal invasion and presence of Underlying causes of irritative voiding
metastasis, as retrograde urography and symptoms include:
*Irritative focus within the bladder—bladder
excretory urography cannot detect these features infection, bladder stone or foreign body,
The role of cytology includes detecting lesions bladder tumor, stone in lower ureter.
that are not seen by imaging or not visually *Urinary tract obstruction—prostate
enlargement, obstructive cystocele.
recognized during cystoscopy or
*Sensory instability—a small capacity bladder
ureterorenoscopy that is excessively sensitive to filling.
TRUS — trans rectal ultrasound *Bladder instability—a bladder that contracts
(squeezes) at inappropriate times and without
mpMRI — multiparametric mri with T2
its owner’s permission.
weighted images *Bladder hyper-reflexia—a bladder that
PCA-3 Test: Not everyone is a candidate for this contracts at inappropriate times as a result of
test, but it may be helpful when there are mixed disease of the brain or spinal cord, including
trauma, strokes, multiple sclerosis, etc.
results from traditional PSA tests, such as: *Poor bladder compliance—a bladder with a
• high PSA level but negative biopsy rigid and poorly elastic wall that cannot
• having cancer despite low PSA levels stretch appropriately as the bladder fills.
• 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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Blddar ca → Eighty percent of urothelial
Obstructive urinary symptoms include: carcinomas will contain some mixed
*Hesitancy—a stream that is very slow to differentiation, most commonly squamous cell.
start. Small cell carcinoma of the bladder should be
*Weak stream—a stream that lacks force or treated as metastatic disease with institution of
pressure. chemotherapy followed by either radiation
*Small caliber stream—a narrow and thinned therapy or surgery.
stream. KUB “kidney-ureter-bladder (KUB) radiography”
*Intermittency—a stream that tends to start
Ureteral access sheaths allow repeated access to
and stop.
*Straining—the need to use the abdominal the intrarenal collecting system without having
muscles to generate a stream. to replace the working guidewire with each
*Prolonged emptying time passage of the endoscope
*Incomplete emptying—the sensation of urine Most protocols
remaining in the bladder after completing include follow-up (cystoscopy+cytology) every 3
months for 18 to 24 months after the initial diagnosis,
urination.
then every 6 months for the following 2 years,
Underlying causes of obstructive voiding then annually, resetting the clock with each newly
symptoms include: identified tumor (Fitzpatrick, 1993).
*Benign prostate gland enlargement bladder ca’da TUR dan önce 3 ü varsa baseline
*Prostate cancer CT: high grade, multiple,
*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

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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