The adrenal glands, also known as adrenal, are located in the retroperitoneum, attached to the upper and medial portions of the renal poles. The gland is divided into the cortex and medulla, which are woven of great activity of hormones, peptide-producing endocrine and neurotransmitters.

The most common diseases that affect the adrenal glands include cortical and medullary tumors.

Cortex tumors are classified as functional and non-functional, depending on whether or not there’s endocrine manifestation. Non-functioning tumors enshrined the term incidentaloma (found casual). The engines are manifested as expansive processes or masses, discovered in the clinical investigation of symptoms and signs peculiar to each type of basic disease due to the secretion of hormones by the cortical layer, or incidentally from imaging scans made with other objectives. The clinical expression of abnormal hormone production stems from the type of hormone produced, what, ultimately, is the product of the histological layer involved in tumoral process.

Aldosterone-producing tumor (hormone produced by the suprarenal) comes from the outer layer of the cortex, the zona glomerulosa, which gives the synthesis of mineralocorticoids. The clinical manifestation is the increase in the circulating blood volume (hypervolemia), arterial hypertension with low Renin, potassium low high, aldosterone, known as primary hyperaldosteronism.

Other tumors of the adrenal cortex are producers of corticosteroids that translate clinically by classic Cushing Syndrome, those producers of sex hormones, which cause virilization or feminization.

There are centripetal obesity (face and torso) face full moon, giba, violaceous streaks, acne, menstrual irregularity, muscle atrophy, sexual impotence, hypertension and diabetes mellitus.

There's usually a urologist's integration with the endocrinologist in the conduct of these patients.

Tumors of the adrenal Medulla are the pheochromocytoma, neuroblastome and ganglioneuroblastome ganglioneuroma.

There are Stromal Tumors, vessels and nerves, cortical hyperplasia, cysts and pseudocysts, infections and abscesses and metastatic tumors.

The most appropriate and effective way of treatment of adrenal tumors is surgical removal.

Laparoscopy can be used successfully to excision and today is the technique used by most of the developed world.

Kidney diseases are divided into benign and malignant.

Obstructive diseases, malformations, diseases of forming kidney stones, urinary tract infectious diseases are benign and can be handled in certain situations with remedies and other surgeries. These are designed to correct the malformations, unblock and remove the stones. Each situation must be examined by a urologist and treated individually.

Sometimes, even in benign disease is necessary the removal of the kidney by surgery. The laparoscopic technique is much used today because it is a minimally invasive technique. There are clinical benign diseases that compromise the renal function and, in these cases, often the treatment is done in teams between a nephrologist (a specialist who treats the clinical diseases of the kidneys) and an urologist. The best example of this is the situation that occurs when a patient loses kidney function and requires replacement of the kidney. The nephrologist does the clinical treatment, uses the artificial kidney (haemodialysis or peritoneal dialysis), prepares the patient for a transplant and the urologist does renal transplant surgery. Again the nephrologist takes sick and makes the patient monitoring transplanted.

Malignant diseases are represented by neoplasms.

Currently are diagnosed more than 200,000 new cases of kidney cancer with index of lethality over 100,000 deaths, the majority attributed to renal cell carcinoma, one of the most aggressive tumors in urological area. Cases diagnosed early, with tumors confined to the kidney, disease-free survival has in 5 years 80-90%, falling to 50-60% in cases of locally advanced disease. Your prognosis is dependent on the stage of disease at diagnosis. The radical nephrectomy is the classic form of treatment of this neoplasia.

In the last two decades, the widespread use of imaging studies of the abdomen-ultrasonography, computed tomography and magnetic resonance imaging-has been responsible for the increase in the diagnosis of renal cell carcinoma. As a result, the incidental detection of renal tumors 4 cm only early-stage, metastatic potential, increased significantly. In this way, the majority of 76%, injuries that present themselves to surgical treatment is ≤ the 4 cm and 86% are T1 stage at diagnosis. Early diagnosis translates into greater survival of patients with kidney cancer and lower rate of disease progression.

During the past decade, the management of these small tumors underwent a major evolution with saving surgery of nephrons, i.e., retires just the tumor and if it preserves the good part of the kidney. This technique achieves survival rates between 90-100% in 10 years.

Some renal cysts can be malignant. There is a classification known as Bosniak which goes from I to IV. The cysts Bosniak type I and II are the only observation. On the other hand, the cysts classified as Bosnisk IV may be cancer and should be treated as such.

The ureters start at what we know with funnel or renal pelvis and end in the bladder. The joint of the pelvis with the ureter known as JUP can present malformation causing difficulty in emptying of urine and needs often a plastic correction, pyeloplasty.

By being an organ of transit in the urine, is in the ureter that have the main causes of urinary tract pain known as renal colic. A calculation can cause a lot of pain to be expelled. 75% of the calculations are eliminated spontaneously and 25% require some type of treatment.

Today it is widely used to power sources and ureteroscopy for fragmentation and subsequent withdrawal of these calculations. The energy source considered most effective is the Laser. Reflux disease, defect in the bladder input that allows urine to the rim at the time of urination, is treated in a clinic and also, depending on the degree of surgical way. Currently this treatment is done, most of the time, endoscopically visualized.

Urothelial cancer can have location within the collector system within the kidney, ureter and bladder. When the tumor is located in the ureter often becomes necessary to remove the entire unit of the affected side.

The urologist requires removing the kidney to the ureter and bladder part where the ureter to deploy.

The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. Benign bladder diseases are more common in women: the urinary infections, anatomical changes known as prolapse or drooping bladder, and urinary incontinence. The non-complicated urinary tract infections usually respond well to medical treatment, as well as changes of function known as neurological disorders of the bladder.

Worldwide the bedwetting is a common problem that affects up to 45% of adult women by reflecting often on deterioration of social life. The most common form is stress urinary incontinence, followed in frequency by urgency incontinence caused by overactive bladder. Because of the shame, the taboo and ignorance of the existence of possible treatments, only a women minority who suffer from incontinence, seek a professional. The World Health Organization defines health not only as the absence of disease but also as well being physical, emotional and social.

The incontinence and urinary prolapse are normally treated by minimally invasive, calls surgeries with use of synthetic fabrics: urinary incontinence by urethral hypermobility with slings and prolapses by minimally invasive approach through high. The screens through vaginas are falling into disuse.

Malignant diseases of the bladder are very difficult to treat, because there is a reservoir in lieu of optimally. Sometimes, one can make a scraping and using vaccines such as BCG, Onco-other times, however, it is required the surgical removal of the bladder. As we need to give a target for urine, we call "deriving incontinence".

The seminal vesicles are two glands that produce a viscous liquid, the seminal fluid that will blend the prostatic secretion and sperm from the excretory duct to form the semen. Is the site produces the largest amount (80%) of the seminal fluid. This fluid nourishes sperm and facilitates their mobility.

Relatively frequent pathology are the so-called congenital cysts or acquired, mostly asymptomatic. Occasionally, can give rise to infectious complications or problems like premature ejaculation, manifesting itself with symptoms similar to prostatitis and urinary symptoms (irritant/obstructive), pelvic pain or infertility. The treatment consists in removal of cyst that can be done by laparoscopy.

Another demonstration clinic that can occur by mucosal hyperplasia of the seminal vesicles is the presence of blood in the ejaculate known as hematospermia. This pathology with this manifestation is considered to be without gravity despite draw attention and worry patients.

The penis is the male sex organ. Its shape is cylindrical, has dimensions ranging typically between 10 and 18 cm when it is erect. It is formed by two corpora cavernosa and corpus spongios and, at its end, there is a crack, which is the termination of the urethra (channel that drains the sperm and urine).

It has, therefore, two functions, reproduction and excretion.

The urethra which passes inside the corpus spongiosum can present infection known as urethritis, may be known with stenosis, narrowing can be malformed with ventral opening called hypospadias or opening dosal called epispadias.

The skin covering the glans is the foreskin. The child can present difficulty of retract by a condition known as phimosis. Many children have redundant prepuce and need to be guided to do always cleaning, because under the skin can deposit the urine and secretions serving as authors factor providing the appearance of disease. The removal of the foreskin, circumcision or postectomia is a way to prevent problems. In diabetic patients is not unusual retraction this skin, even in the elderly forming a ring known as Paraphimosis.

Sores, warts and even cancer can settle in this part of the body. A relatively frequent disease is the tortuosity of the penis when erect, Peyronie's disease. When the tortuosity prevents sexual intercourse, the urologist deals with medicines, with corrective surgery or in extreme cases, putting a prothesis.

The scrotum or testicular/purse bag is a protuberance of skin and muscle containing the testicles. It is an extension of the abdomen, and is located between the penis and the anus. The function of the scrotum is to keep the testicles at a temperature lower than the rest of the body (34.4 degrees Celsius). The excessive heat destroys the sperm. Having as one of its layers a muscle, the scrotum contracts and relaxes, as is necessary to increase or decrease, respectively, the temperature inside. Some diseases like Hydrocele (water in the bag), varicocele (dilated veins) can increase the local temperature and need surgical treatment.

During puberty, the testes grow to spermatogenesis. Its size depends on the sperm production (amount of spermatogenesis being made in the testicles), seminal fluid and fluid production of Sertoli cells. After puberty, testicular volume can be increased by up to 500% when compared with the size before puberty.

The function of the testicles is the production of cells responsible for fertilization: sperm. In addition to sperm production, the testicles are also mainly responsible for the production of male hormones, with remark for testosterone. These control the development of some human characteristics such as the growth of body hair, voice, beard, width of the bones or muscular development. It is more common that one of the testicles is hanging a bit lower than the other. The percentage of men with lower left testicle and testicle lower right is practically equal. This is due to differences in vascular anatomical structure on the left and right sides. The testicles are very sensitive to impact and injury.

The main diseases of testicles are: testicular cancer and other neoplasms; Testicular swelling caused by hydrocele; inflammation of the testes called Orchitis; inflammation of the epididymis called epididymitis; torsion of the spermatic cord, also called testicular varicocele detorção; swelling of the veins of the testes, usually affecting the left nut; and monorquismo, which is the absence of one or both testicles. The removal of one or both testes is called orchiectomy, in medicine (orchiectomy and orquectomia are synonyms), and castration, in general use, especially when done as punishment or torture.

There are testicular protheses to simulate the look and feel of one or both testes, for when they are absent due to an injury or as a treatment for gender identity disorders.

The epididymis is a small duct which collects and stores the sperm produced by the testis. It is located behind the testicle in the scrotum and ends at the base of the vas deferens the channel that carries the sperm to the prostate.

The epididymis is as long as the testis, "C" shaped flat, along the side of the testicle. After being stored in the epididymis, sperm goes through the vas deferens to the prostate gland, where it mixes with semen originating from the seminal vesicles, the prostate gland by moving the urethra during ejaculation.

The urethra is a tube that connects the urinary bladder to the outside of the body.

In males, the urethra is the conduit for semen during sexual intercourse. It also serves as a passage for urine to flow. In females, the urethra is shorter and emerges above the vaginal opening.

The external urethral sphincter is a striated muscle that allows voluntary control over urination.

Urethra diseases

• Hypospadias and epispadias are forms of abnormal development of the urethra in the male, where the meatus is not located at the distal end of the penis (it occurs lower than normal with hypospadias, and higher with epispadias). In a severe chordee, the urethra can develop between the penis and the scrotum;
• Infection of the urethra is urethritis, said to be more common in females than males. Urethritis is a common cause of dysuria (pain when urinating);
• Related to urethritis is so called urethral syndrome;
• Passage of kidney stones through the urethra can be painful, which can lead to urethral strictures;
• Cancer of the urethra.

1. What is the prostate?

   The prostate is an internal gland of the male reproductive system.  It looks like a very small apple and it is just below the bladder. Weighs about 20 grams.

2. Prostate function

   The function of the prostate is to secret a slightly alkaline that usually constitutes 50–75% of the volume of the semen along with spermatozoa and seminal vesicle fluid.

   Inside the prostate is the transformation of the main male hormone, testosterone, into dihydrotestosterone, which, in turn, is responsible for the control of the growth of this gland.

3. Benign prostate diseases

   3.1. Benign Prostatic Hyperplasia (BPH)

   Normal prostate growth is related to the age;

   From the 31 years the prostate begins to grow 0.4 g per year;

   Can reach volumes of 60 g to 100 g and more.

   Attention: The BPH and prostate cancer have some similar symptoms.
   Patients with BPH who are in treatment should be subject to annual examinations, to follow the evolution of improvement, as well as for early detection of cancer in this region.

   3.1.1. Treating BPH

   • With drugs-Alpha-blockers, Finasterides and dutasterides;
   • Alpha-blockers and dutasterides together;
   • Treatments by urethra (channel) when the prostate has less than 75 g;
   • Transurethral Monopolar Resection;
   • Transurethral Bipolar Resection;
   • Prostate Laser vaporization (Green Laser);
   • Vaporization of the prostate with Plasma Button;
   • Treatment by surgery when the prostate has more than 75 g;
   • Open Prostatectomy (opening the belly);
   • Prostatectomy by Lrp-Technical Mirandolino Technique.

     3.1.1.1. The Mirandolino’s Technique

     Until the end of the 20th century surgery for benign prostatic hyperplasia was opened, through technical retropubic by Irish surgeon Terence Millin (1947). In 1999, Dr. Mirandolino Mariano makes the first laparoscopic surgery, publishing case report of the technique in 2002, in Journal of the American Urological Association.

     First described in the article Laparoscopic Prostatectomy with Vascular Control for Benign Prostatic Hyperplasia, with vascular control, without bleeding, the technique is indicated for prostate above 75 grams. In 2005, Dr. Mirandolino publishes new article, this time in Journal of European Urology Association with 60 cases’ experience (1999-2005): Laparoscopic Prostatectomy for Benign Prostatic Hyperplasia – Six-Year Experience.

     Mirandolino’s technique is a paradigm of the medicine’s evolution in one century. In 1896, the prostate surgery for benign disease performed by the Irish surgeon Peter Freyer opened the abdomen and then the bladder to remove the prostate through the bladder. Led to much bleeding, difficulty narrowing of the urethra and therefore was used for a few years. In 1905, Yank did surgery via perineal, which not evolved.

     These two incipient techniques were used until 1934 when Joseph McCarthy used scraping by inside the urethra to remove part of the prostate. Until today that’s the best technique for prostate from 20 to 40 grams.

     In 1947, another Irish surgeon, Terence Millin, developed retropubic surgery: to open the abdomen and going directly to the prostate. The new technique with laparoscopy is performed half a century later, in 1999, by Dr. Mirandolino Mariano in Brazil. The Mirandolino’s technique was adopted initially in the USA, Colombia and some countries of Europe and more recently in Brazil. Many doctors trained by Dr. Mirandolino in several courses, as the Urovídeo, Goiânia, now use the technique.

   3.2. Prostatitis

   The treatment of prostatitis is made with antibiotics.

4. Prostate cancer

   It is currently the most frequent men’s cancer, representing 16% of total cases.

   4.1. Prevention

   • Healthy eating
   • Control of obesity
   • Practice of physical exercises regularly
   • Routine medical consultation

   4.2. When looking for a doctor?

   • Without symptoms: after 40 years once a year
   • With symptoms: seek medical advice immediately

   4.3. Symptoms

   • Delay to start urination
   • Effort to end urination
   • Extension of time of urination
   • Voiding choppy Jet, splitting the urination in 2 or more times
   • Difficulty urinating with full bladder

   4.4. The evolution of the disease

   In the early stages, is confined to the prostate. If left untreated, can invade nearby organs as seminal vesicles, urethra and bladder.

   Can spread to distant organs such as the lymph nodes, bones, liver and lungs, when it becomes incurable.

   • Limited to a Carcinoma prostate Wolf (image 22)
   • Advancing reaching the bladder Carcinoma (picture 23)
   • Prostate Carcinoma by advancing through the bladder, peritoneum and rectal wall (picture 24)

   4.5. Epidemiological studies

   • Rare before the age of 50 years and its incidence increases progressively with age;
   • About 60% of men over 80 years have primary prostate cancer (Pathology);
   • The incidence is somewhat higher in families of carriers of the disease.
     Important!
     Produce clinical signs only when the cancer reaches the prostatic capsule → advanced disease.
     In the early stages the tumor can only be identified through routine clinical examinations → annual Digital Rectal Examination (DRE) in every man over 50 years of age.

   4.6. How the diagnosis is made

   • By the presence of urinary symptoms
   • By DRE
   • By a blood test (PSA)
   • By prostate ultrasound
   • For other tests, depending on the case (scintigraphy, computed tomography, magnetic resonance, etc.)

   4.6.1. Digital rectal examination

   • Represents the more accurate way to identify cases of prostate cancer (picture 30)
   • It is not a "former" or "overcome"
   • Does not compromise the masculinity, nor is unworthy

   4.6.2. PSA Examination

   Normal prostate 20 g

   • 40 years - up to 2.5
   • 50 years - up to 3.5
   • 60 years - up to 4.5
   • 70 years - up to 5.5
   • 80 years - up to 6.6

   4.6.3. Biopsy

   It is a simple procedure with local anesthesia or sedation, guided by US.

   Is indicated when:

   • Palpable prostate nodule (hardening)
   • Elevation of PSA
   • Previous suspected pathology
   • Biochemical relapse
   • Active surveillance
   • ASAP

   When repeat:

   • Persistence of elevated PSA
   • High grade PIN
   • ASAP
   • Inadequate sample
   • Active surveillance
     

   Interpretation of results:

   • By sextants
   • Gleason
   • Number of cylinders
   • Percentage of cylinders
   • Perineural infiltration

   4.7. Cancer treatment

   When diagnosed in early stage, treatment goals:

   • Cure
   • Continence
   • Potency

   4.7.1. Radical Prostatectomy

   Can be accomplished by the following methods:

   • Retropubic
   • Laparoscopic
   • Robotics

   4.7.2. Brachytherapy

   4.7.3. Radiotherapy

   4.7.4. Hormone therapy

   4.7.5. Cryosurgery