LABIAL ADHESIONS AND FUSION
DESCRIPTION Complete (fusion) or partial adherence of labia minora. Low estrogen levels contribute to a thin atrophic lining, which is easily denuded and later heals with adhesions. The condition is acquired, not found at birth, and occurs in prepubescent girls and postmenopausal women. Fecal soiling as an infant, vulvovaginitis, eczema, dermatitis, and sexual abuse may be inciting factors. It may cause voiding dysfunction in severe cases, with resulting hydroureteronephrosis.
SYNONYMS
• Acquired postinflammatory cohesion of the labia minora
• Vulvar fusion
• Synechiae of the vulva
TREATMENT
• Conjugated estrogen cream locally applied
• Surgical treatment for severe cases
REFERENCE
Tebruegge M, Misra I, Nerminathan V. Is the topical application of oestrogen cream an effective intervention in girls suffering from labial adhesions? Arch Dis Child. 2007;92(3):268–271.
LACTATE DEHYDROGENASE (LDH), UROLOGIC CONSIDERATIONS
DESCRIPTION LDH is a cellular enzyme useful in monitoring the treatment of GCT. It tends to have a low specificity (further impaired in smokers), and therefore must be correlated with other clinical findings and lab markers (ie, α-fetoprotein and β-hCG). Some correlation has been made between LDH and tumor bulk. LDH can also be elevated in cases of liver involvement by other tumors such as RCC.
REFERENCE
Barlow LJ, Badalato GM, McKiernan JM. Serum tumor markers in the evaluation of male germ cell tumors. Nat Rev Urol. 2010;7(11):610–617.
LAPIDES CLASSIFICATION OF VOIDING DYSFUNCTION
DESCRIPTION A historic system for categorizing neurogenic voiding dysfunction into 5 areas:
• Sensory neurogenic bladder: Interrupted afferent bladder sensation can lead to chronic bladder distension and deterioration. Common processes include diabetes mellitus, tabes dorsalis, and pernicious anemia.
• Motor paralytic bladder: Destruction of parasympathetic motor innervation to the bladder results in painful overdistension initially and inability to initiate and maintain micturition. Common processes include pelvic surgery or trauma and possibly herpes zoster.
• Uninhibited neurogenic bladder: Injury to the corticoregulatory tract of the sacral spinal cord (micturition reflex center) leads to frequency, urgency, and urge incontinence. Common processes include cerebrovascular accident, brain or spinal cord tumor, Parkinson disease, and demyelinating disease.
• Reflex neurogenic bladder: Complete interruption of sensory and motor pathways between the sacral spinal cord and brainstem leads to lack of bladder sensation and inability to voluntarily micturate. Common processes include trauma and transverse myelitis.
• Autonomous neurogenic bladder: Complete motor and sensory separation from the sacral spinal cord leads to inability to voluntarily micturate and lack of reflex bladder activity and bladder sensation.
REFERENCE
Voiding dysfunction: Diagnosis, Classification and management. In: Gillenwater JY. Adult and Pediatric Urology. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.
LASER TECHNOLOGIES AND UROLOGIC APPLICATIONS
DESCRIPTION The use of laser (short for “light amplification by stimulated emission of radiation”) systems in urologic surgical practice has gained widespread acceptance. The primary mechanism of laser operating systems is based on the process of stimulated emission of radiation where excited electrons rapidly decay and emit photon energy, which leave a resonator cavity as a coherent laser beam.
Lasers impart 4 different effects: Thermal, mechanical, photochemical, and tissue-welding effects. The thermal effect is most commonly employed. The laser light energy is absorbed and transformed into heat. The heat denatures proteins at 42–65°C, shrinks arteries and veins at 70°C, and cellular dehydration at 100°C. After water has evaporated from the tissue, the temperature rapidly rises, with carbonization at 250°C, and vaporization occurs at 300°C. Mechanical effects are used to create a plasma bubble that expands rapidly to disrupt stones. Photochemical effects involve laser activation of specific drugs or compounds taken up by the tissue and tissue welding relies upon collagen cross-linking using materials activated by a lasers specific wavelength.
Conditions such as nephrolithiasis, benign prostatic obstruction (BPO), bladder cancer, kidney cancer, urothelial cancer, and stricture disease have all been treated by laser therapy. Some modern laser systems include potassium titanyl phosphate (KTP), neodymium:yttrium-aluminum-garnet (Nd:YAG), holmium:yttrium-aluminum-garnet (Ho:YAG), and semiconductor diode lasers. The frequency-doubled, double-pulse Nd:YAG (FREDDY) laser is a short-pulsed, double-frequency solid-state laser with wavelengths of 532 and 1064 nm. It is a low-power, low-cost laser developed for intracorporeal lithotripsy. CO2 lasers are used for ablation of skin lesions such as condylomata. The thulium:YAG laser has been developed improve on some of the shortcomings of the Ho:YAG laser. This new laser more closely matches the water absorption peak in soft tissue to minimize collateral tissue damage. The methods of laser delivery can include end firing, side firing, and interstitial technologies with many fibers designed to fit trough endoscopes. Specific clinical applications:
• Soft tissue incisions (eg, strictures, posterior urethral valves, endopyelotomy, bladder neck contractures): Ho:YAG, Nd:YAG, or KTP.
• Resection and tissue ablation (eg, BPH, bladder cancer, condylomata, penile cancer, hemangiomata), use Nd:YAG, Ho:YAG, KTP:YAG, semiconductor diode, or CO2.
• Lithotripsy (renal pelvis, ureter, bladder stones): Ho:YAG, FREDDY, pulsed dye, or alexandrite.
• Tissue welding (eg, vasovasotomy; urethral reconstruction for hypospadias): Diode, KTP, Nd:YAG, or CO2.
• Laser hair removal (eg, perineal skin used for local urethral grafts): Alexandrite, semiconductor diode, or Nd:YAG.
REFERENCES
Zarrabi A, Gross AJ. The evolution of lasers in urology. Ther Adv Urol. 2011;3(2):81–89.
Grasso, M. Lasers in Urology in Medscape. http://emedicine.medscape.com/article/445722-overview, Accessed March 3, 2014.
LAURENCE–MOON–BARDET–BIEDL SYNDROME
DESCRIPTION This autosomal recessive disease was initially described in 1860 by Laurence–Moon and received a more exact description in 1920 by Bardet–Biedl. A wide variety of manifestations include retinal pigmentary dystrophy (previously termed retinitis pigmentosa), postaxial polydactyly, central obesity, mental retardation, and hypogenitalism. More recently, renal abnormalities have been described, including chronic glomerulonephritis, characteristic cystic tubular disease, lower urinary tract malformations, and defects of tubular concentrating ability. Renal failure is the major cause of morbidity and early mortality. Undescended or maldescended testes can be present neonatally in up to 25% of males.
SYNONYMS
• Bardet–Biedl syndrome: More general, including all of the above description
• Laurence–Moon syndrome: Much rarer; differs with the above description, including progressive spastic paraparesis and distal muscle weakness but without polydactyly
REFERENCES
Beales PL, Warner AM, Hitman GA, et al. Bardet-Biedl syndrome: A molecular and phenotypic study of 18 families. J Med Genet. 1997;34(2):92–98.
Bahceci M, Dolek D, Tutuncuoglu P, et al. A case series of Bardet-Biedl syndrome in a large Turkish family and review of the literature. Eat Weight Disord. 2012;17(1):e66–e69.
LAZY BLADDER SYNDROME (NURSE’S BLADDER)
DESCRIPTION 1st described by Swenson in 1962, this condition occurs when children exhibit holding behavior and void infrequently. Thought to be caused by the continuous voluntary suppression of the normal desire to void, it is more common in girls. Patients are prone to develop UTIs due to urinary stasis and often have problems with constipation. Some patients have overflow or stress incontinence. The VCUG shows a large smooth-walled bladder, and US of the upper tract is usually normal. Urodynamic studies show large bladders with decreased sensation during bladder filling, low pressures, and large postvoid residuals. Timed voiding schedules, antibiotic suppression, biofeedback bladder training, and intermittent catheterization are all options for treatment.
REFERENCES
Grasso M, Torelli F, Blanco S, et al. Vesicoureteral reflux in the child with lazy bladder syndrome: The infrequent voider. Adv Urol. 2008:432576.
Bauer SB, Retik AB, Colodny AH, et al. The unstable bladder of childhood. Urol Clin North Am. 1980;7:321–336.
LEADBETTER–CLARKE URETERAL ANASTOMOSIS
DESCRIPTION A nonrefluxing anastomosis is created by making a longitudinal incision through the taenia, just outside the mucosa. The ureter is laid over the mucosa and a small buttonhole is made through the mucosa to anastomose the spatulated end of the ureter. The taenia is closed over the ureter.
REFERENCE
Porena M, Mearini L, Zucchi A, et al. Ureterointestinal anastomosis in orthotopic neobladders. Urol Int. 2000;64(4):181–184.
LEADBETTER–POLITANO URETERONEOCYSTOSTOMY
DESCRIPTION Through a transvesical exposure, the ureter is mobilized from the bladder wall and surrounding peritoneum. A new ureteral hiatus is created 2–3 cm above the old hiatus. The ureter is then delivered behind the entire bladder, through the new hiatus and tunneled submucosally toward the old hiatus, where it is reimplanted.
REFERENCE
Kay R. Reimplantation of the ureter. In: Novick AC, Streem SB, Pontes JE, et al., eds. Stewart’s Operative Urology. Baltimore, MD: Williams & Wilkins; 1989:526–538.
LEAK POINT PRESSURE (LPP)/ABDOMINAL LEAK POINT PRESSURE (ALPP)
DESCRIPTION LPP is a urodynamic variable. Abdominal leak point pressure (ALPP), related to stress urinary incontinence (SUI), is the lowest abdominal pressure required to cause urinary leakage during either a Valsalva maneuver or a cough in the absence of a detrusor contraction. An ALPP of <60 cm H2O suggests significant intrinsic sphincter deficiency (ISD). If the ALPP is –90, it suggests mild sphincter deficiency. Sphincter deficiency is minimal with an ALPP >90 cm H2O. Detrusor leak point pressure (DLPP) is the lowest detrusor pressure required to cause urinary leakage in the absence of a detrusor contraction or increased abdominal pressure. High DLPP (>40 cm H2O) may put patients at a higher risk for upper urinary tract deterioration.
REFERENCE
Kim SO, Kim YJ, Yoo DH, et al. Clinical factors associated with low valsalva leak point pressure among women with stress urinary incontinence. Int Neurourol J. 2011;15(4):211–215.
LeBAG NEOBLADDER
DESCRIPTION This is a modification of the Mainz I orthotopic neobladder, which uses only 1 ileal limb instead of 2. The detubularized colon and a single segment of ileum can be joined using met al staplers to create a broad intestinal plate, which is then converted into a pouch with a ureterocolonic and urethral anastomosis.
REFERENCE
Pannek J, Senge T. History of urinary diversion. Urol Int. 1998;60(1):1–10.
LeDUC URETERAL ANASTOMOSIS
DESCRIPTION The end of the small bowel segment is opened 4–5 cm and a longitudinal incision is made in the mucosa, which is then raised. At the distal end of this incision, a hole is made through the wall. The ureter is pulled through this opening and laid in the mucosal incision. The mucosa is then sutured to the side of the ureter.
REFERENCE
Evangelidis A, Lee EK, Karellas ME, et al. Evaluation of ureterointestinal anastomosis: Wallace vs Bricker. J Urol. 2006;175(5):1755–1758.
LEIOMYOMATOSIS, HEREDITARY
DESCRIPTION Familial cancer syndrome of a triad of cutaneous leiomyomas, uterine leiomyomas, and type 2 papillary RCC. Renal tumors tend to be solitary and unilateral and are likely to be aggressive; collecting duct RCCs have also been observed. The lesions are usually seen in women 20–35 yo. Given their aggressive nature, the prompt surgical resection of renal tumors is recommended. (See also Section II: “Reed Syndrome.”)
REFERENCE
Coleman JA. Familial and hereditary renal cancer syndromes. Urol Clin N Am. 2008;35(4):563–572.
LEOPARD SYNDROME
DESCRIPTION An autosomal dominant condition similar to Noonan syndrome, except for multiple lentigines (macule pigment accumulation within the dermis and epidermis). LEOPARD syndrome is the mnemonic for lentigines, ECG abnormalities, ocular hypertelorism/obstructive cardiomyopathy, pulmonary valve stenosis, abnormalities of genitalia in males, retardation of growth, and deafness. Cardiomyopathy is an important feature because it is associated with significant mortality. Genital hypoplasia in males, including a small penis and small, often undescended testicles, is the most common association. Hypospadias and delayed puberty may also be found.
SYNONYMS
• Multiple lentigines syndrome
• Progressive cardiomyopathic lentiginosis
TREATMENT
Orchiopexy, repair of hypospadias
REFERENCE
Coppin BD, Temple IK. Multiple lentigines syndrome (LEOPARD syndrome or progressive cardiomyopathic lentiginosis). J Med Genet. 1997;34(7):582–586.
LERICHE SYNDROME
DESCRIPTION Described in 1923 as symptoms characteristic of thrombotic occlusion of the terminal aorta, this syndrome is caused by atherosclerosis of the arterial wall, with thrombus and gradual occlusion. Symptoms include fatigue of both lower limbs, symmetrical atrophy of lower extremities, pallor of legs/feet, and an inability to maintain a stable erection due to inadequate arterial flow to the penis (hypogastric arterial obstruction). Gradual occlusion allows for collateral circulation; therefore, acute symptoms are unlikely.
SYNONYM
Gradual thrombotic obliteration of the abdominal aorta and iliac arteries
TREATMENT
Bypass graft from the aorta to iliac or common femoral arteries
REFERENCE
Setacci C, Galzerano G, Setacci F, et al. Endovascular approach to Leriche syndrome. J Cardiovasc Surg (Torino). 2012;53(3):301–306.
LESCH–NYHAN SYNDROME
DESCRIPTION 1st described in 1964 as an X-linked recessive disorder associated with failure to form hypoxanthine phosphoribosyltransferase, this disorder is caused by loss of function of the enzyme hypoxanthine guanine posphoribosyltransferase. Manifestations are hyperuricemia and uric acid lithiasis, choreoathetosis, mental retardation, spastic cerebral palsy, and self-mutilation of fingers and lips by biting. Allopurinol is the main urologic intervention to reduce hyperuricemia.
REFERENCE
Ngo TC, Assimos DG. Uric acid nephrolithiasis: recent progress and future directions. Rev Urol. 2007;9(1):17–27.
LEUKEMIA, UROLOGIC CONSIDERATIONS
DESCRIPTION Leukemic infiltration of the testicle can be seen in children with acute lymphoblastic leukemia (ALL). The typical presentation is testicular enlargement, typically bilateral. Open testicular biopsy, bilaterally, should be performed along with bone marrow and CSF analysis for tumor recurrence. Orchiectomy is not indicated for leukemic infiltration. Testes were once a common site of relapse, but with current intensive chemotherapy regimens, the testicular relapse rate is <5%. No strong evidence suggests an increase in birth defects in the children of leukemia survivors. Patients treated with cyclophosphamide-containing regimens are at risk for hemorrhagic cystitis and long-term urothelial tumors. (See also Section I: “Cystitis, Hemorrhagic [Infectious, Noninfectious].”)
TREATMENT
• If the testicle is the isolated site of relapse, local irradiation (up to 20 Gy) to both testes and reinstitution of systemic chemotherapy can be curative.
• Therapy can cause irreversible damage to seminiferous tubules and Leydig cells.
Patients can develop hypogonadotropic hypogonadism and low testosterone with azoospermia.
REFERENCES
Kulkarni RK, Marwaha RK, Trehan A, et al. Testicular relapse in childhood acute lymphoblastic leukemia: The challenges and lessons. Indian J Cancer. 2010;47:134–138.
Pui CH, Rivera GK. Acute lymphoblastic leukemia. In: Rudolph AM, ed. Rudolph’s Pediatrics. 19th ed. Norwalk, CT: Appleton & Lange; 1991.
LEUKOPLAKIA, PENIS
DESCRIPTION Solitary or whitish plaques with hyperkeratosis, parakeratosis, and hypertrophy of the squamous rete pegs, with edema and lymphocytic infiltration. The condition often involves the penile meatus and has been associated with in situ squamous cell carcinoma (SCC) and verrucous carcinoma.
TREATMENT
• Eliminate chronic irritation
• Circumcision
• Surgical excision with periodic biopsy of incompletely excised lesions
REFERENCE
Bissada NK. Conservative extirpative treatment of cancer of the penis. Urol Clin N Am. 1992;19(2):283–290.
LEUKORRHEA
DESCRIPTION Generally refers to nonmalodorous, mucous like, white, or yellowish vaginal discharge in the absence of any pathologic cause. The quantity and quality vary among individuals, and mild irritative symptoms can be normal. Leukorrhea is also seen during infancy secondary to maternal estrogens, as well as during puberty secondary to estrogen surges. Reassurance is all that is necessary if the cervical and vaginal exam is normal, vaginal pH is normal (<4.5), and there are normal findings on microscopy and a negative amine test. (See also Section II: “Vaginosis”; Section III: “Vaginal Discharge Algorithm.”)
REFERENCE
Anderson AU, Karasz A, Friedland S. Are vaginal symptoms ever normal? A review of the literature. MedGenMed. 2004;22:49.
LICHEN NITIDUS, PENIS
DESCRIPTION An uncommon chronic inflammation appearing as flesh-colored papules with sharp demarcations and flat, shiny, and slightly elevated surfaces. The etiology is unknown, but it is believed to be a variant of lichen planus. Histologically, lymphocytes, histiocytes, and melanophages form a ball-like structure covered by epidermis with a characteristic claw-like projection of the rete ridges. The condition is usually asymptomatic.
TREATMENT
• Spontaneous healing is common
• Oral histamines
• Topical antipruritics and topical corticosteroids may be helpful
REFERENCE
Davis DA, Skidmore RA, Woosley JT. Lichen nitidus. Urology. 1996;47(4):573.
LICHEN PLANUS, PENIS
DESCRIPTION An uncommon pruritic inflammation of the skin, which typically occurs on the penile glans. Benign, it is characterized by pruritic, violaceous, and flat-topped papules. Histologically, there can be degeneration of the basal cell-layer keratinocytes and dense infiltration of lymphocytes in the upper dermis hugging the epidermis. Multiple lesions occur and can ulcerate. Differential diagnoses include secondary syphilis, bowel disease, psoriasis, Zoon balanitis, and squamous cell carcinoma (SCC). There is no specific treatment; symptomatic relief is obtained through antihistamines, ataractics, and topical lotions.
REFERENCE
Hoshi A, Usui Y, Terachi T. Penile carcinoma originating from lichen planus on glans penis. Urology. 2008;71(5):816–817.
LICHEN SCLEROSIS ET ATROPHICUS
DESCRIPTION An uncommon cutaneous disorder with a female predominance. Early lesions are characterized as either white macules, which may coalesce into patches, or flat, white, or pink-depressed papules and plaques. Confluence of the papules and marked hyperkeratosis and atrophy may develop. Extra-genital areas (eg, arms, shoulders, trunk, neck, and face) are less commonly affected in men. Dysuria, pruritus, and pain are associated with the disease process. Squamous cell carcinoma (SCC) has been reported to occur.
SYNONYMS
• Lichen sclerosis
• The late stage evolves into balanitis xerotica obliterans
TREATMENT
• Circumcision
• Topical treatments for nongenital areas
REFERENCE
West DS, Papalas JA, Selim MA, Vollmer RT. Dermatopathology of the foreskin: An institutional experience of over 400 cases. J Cutan Pathol. 2013;40(1):11–18.
LICHEN SIMPLEX CHRONICUS (LICHEN SIMPLEX COMPLEX)
DESCRIPTION Localized chronic pruritus with patches of dermatitis, resulting from chronic scratching/rubbing. Common sites are the perineum, thigh, scrotum, and vulva. The lesions appear as multiple oval plaques that become thickened and scaly. There is a whitish gray discoloration caused by lichenification and maceration. The skin may become more susceptible to secondary infection and allergic contact dermatitis. Etiologies include contactants (irritant and allergic), infection, and underlying dermatoses. Microscopically, the lesions resemble chronic dermatitis with hyperkeratosis and parakeratosis. Diagnosis is usually clinical, but biopsy may be necessary.
SYNONYM
Circumscribed neurodermatitis
TREATMENT
• Break the scratch-itch cycle
• Stop all irritants
• Sitz baths or soaks
• Open wet compresses to affected areas
• Systemic antipruritics and/or sedating medications may be necessary to lessen the itching
• Topical and occasionally systemic steroids are necessary
REFERENCE
Margesson LJ. Vulvar disease pearls. Dermatol Clin. 2006;24(2):145–155.
LICH–GREGOIR URETERAL REIMPLANTATION
DESCRIPTION This extravesical, less invasive repair does not disrupt the ureteral trigonal continuity. A 4–5-cm trough is created by dissecting the detrusor of the mucosa, and the mobilized ureter is placed in the trough with the detrusor closed over it.
REFERENCE
Kay R. Reimplantation of the ureter. In: Novick AC, Streem SB, Pontes JE, eds. Stewart’s Operative Urology. Baltimore: Williams & Wilkins; 1989:526–538.
LIDDLE’S SYNDROME
DESCRIPTION Liddle’s syndrome is an autosomal dominant disorder of the sodium channels of the collecting duct. Mutations in the epithelial sodium channels in the kidney result in increased activity and severe hypertension is typically the result. Features of hypokalemia and metabolic alkalosis can also occur mimicking primary hyperaldosteronism. Treatment generally focuses on a low salt diet in conjunction with a potassium-sparing diuretic.
REFERENCE
Guay-Woodford L. Hereditary nephropathies and developmental abnormalities of the urinary tract. In: Goldman L, Schafer A, eds. Goldman’s Cecil Medicine. Philadelphia, PA: Elsevier Saunders; 2011:802.
LIFE EXPECTANCY, UROLOGIC CONSIDERATIONS
DESCRIPTION Life expectancy is commonly used by urologists when determining therapy for localized prostate cancer, as age may influences choice of treatment.
REFERENCE
Social Security Administration. Available at www.socialsecurity.gov, Accessed May 15, 2013.
LIPOMA, BLADDER
DESCRIPTION Bladder lipoma is a rare entity. It can be associated with a pelvic lipoma, and has been reported to cause bladder outlet obstruction. A capsule circumscribes the homogeneous, sharply marginated fat. It is benign and must be distinguished from liposarcoma, angiolipoma, and cystic teratoma, usually by CT. Treatment is by surveillance, unless symptomatic. (See also Section II: “Bladder Mass.”)
REFERENCE
Kunkle DA, Mydlo JH. Bladder wall lipoma in patient with irritative voiding symptoms. Urology. 2005;66(3):653–654.
LIPOMA, SPERMATIC CORD
DESCRIPTION Benign lobulated preperitoneal fat that can project down the cord. Accounts for up to 90% of spermatic cord tumors and is most commonly seen in adults. Histologic variants include angiolipoma, fibrolipoma, fibromyxolipoma, myxolipoma, and myxoid myolipoma. The lesion can present as a mass, and must be distinguished from adenomatoid tumor, leiomyoma, fibroma, liposarcoma, leiomyosarcoma, and fibrosarcoma. (See also Section I: “Spermatic Cord Mass.”) Complete excision at time of surgery is recommended.
REFERENCE
Cavazzola LT, Lieberknecht M, Machado AS, et al. Giant lipoma of the spermatic cord. Am J Surg. 2009;198(5):e54–e55.
LIPOMATOSIS, PELVIC
DESCRIPTION Pelvic lipomatosis was 1st described in 1959 as an overgrowth of fat in the perirectal and perivesical regions that can cause compression of the lower urinary tract and lead to uremia. Rare disease found primarily in men in the 3rd–6th decades of life. Approximately 2/3 of patients are African American, with an 18:1 male-to-female ratio. Lipomatous tissue is composed of mature adipose and may be associated with inflammation. Histopathologically, it is found to be dense, vascular, unencapsulated lipomatous tissue that commonly envelops the pelvic viscera. It differs from a simple lipoma by the fact that it does not arise from a single focus, is not encapsulated, and does not expand centrifugally. Clinical features vary from urinary frequency to constipation. Pelvic lipomatosis has been associated with a higher incidence of hypertension. On a plain abdominal x-ray, it presents with radiolucency of the perivesical areas. Other radiographic signs include an elongation and elevation of the bladder, and the rectum and sigmoid colon. There is widening of the retrorectal space with increased lucency of the pelvic sidewalls. On cystography, a full bladder has an abnormal shape (banana shape) and position (superiorly as well as anteriorly). Cystoscopy should be performed, as there are reports of associated cystitis glandularis. Surgical removal of the fat (difficult and feasible in selected few patients) may be possible. For those patients with obstructive uropathy, treatment options include ureteral stenting, nephrostomy tubes, ureteral reimplantation, or urinary diversion. Pelvic exploration is done with caution as the normal anatomic planes are disrupted by the infiltrating fat.
REFERENCE
Trilla Herrera E, Torrecilla Ortíz C, Muñoz Seguí J, et al. Pelvic lipomatosis: Clinical review and report of four new cases. Actas Urol Esp. 2000;24(5):423–428.
LIPOMENINGOCELE, UROLOGIC CONSIDERATIONS
DESCRIPTION A meningocele associated with an overlying lipoma. This condition belongs to the family of occult spinal dysraphisms in which the formation of the spinal column is affected but does not result in an open vertebral canal. Outward signs and symptoms may be subtle, and the neurologic exam may be normal. As children get older, they may present with absent perineal sensation, back pain, secondary incontinence (incontinence after initial period of dryness), recurrent UTIs, or fecal soiling. In children <3 yo, urodynamic testing may be normal but it is usually abnormal in children >3 yr.
Address urinary symptoms as appropriate after urodynamic testing, and refer to a neurosurgeon for evaluation of tether release to prevent further injury and growth.
REFERENCE
Rendeli C, Ausili E, Tabacco F, et al. Urodynamic evaluation in children with lipomeningocele: Timing for neurosurgery, spinal cord tethering and follow-up. J Urol. 2007;177(6):2319–2324.
LIVER METASTASIS, UROLOGIC CONSIDERATIONS
DESCRIPTION The liver is a primary site for many malignant neoplasms, including those arising in the GU tract. Urothelial carcinoma (TCC), renal cell carcinoma (RCC) and testicular carcinoma may spread to the liver, but metastasis is most commonly seen in prostate cancer. In addition to bone pain and spinal cord compression, liver metastasis can be very painful. A liver lesion itself should not affect the urinary tract, but extensive disease may be reflected in increased bilirubin and urobilinogen levels on urine analysis.
TREATMENT
• Evaluate and treat primary tumor.
• Segmental resection or locally ablative therapies may be appropriate (Image 
).
REFERENCE
Campbell SC, Lane BR. Malignant renal tumors. In: Wein AJ, et al., eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2012:1413–1474.
LOBAR NEPHRONIA
DESCRIPTION A renal mass caused by acute focal infection without liquefaction. Clinical characteristics most frequently encountered are fever, flank pain, or back pain. Uroradiographic findings in this condition can mimic a renal abscess or neoplasm. Bacterial infection (E. coli, Klebsiella, Aerobacter aerogenes, Proteus, Pseudomonas) and Candida albicans are common causes. Appropriate medical treatment will cause the infected mass to disappear, but scarring may occur. (See also Section I: “Pyelonephritis, Acute, Adult.”)
SYNONYMS
• Acute lobar nephronia
• Acute focal bacterial nephritis
TREATMENT
• IV antibiotics
• Radiologic surveillance: CT or US
REFERENCE
Papanicolaou N, Pfister RC. Acute renal infections. Radiol Clin North Am. 1996;34(5):965–995.
LORD PROCEDURE (HYDROCELECTOMY)
DESCRIPTION During the Lord procedure for hydrocelectomy, radial sutures are used to gather the sac around the posterior aspect of the testis and epididymis. It was initially developed in 1964 to reduce the rate of postoperative hematoma formation after hydrocelectomy. This technique does not require dissection of the hydrocele sac and therefore can be relatively bloodless. Generally this technique is recommended for thin-walled hydroceles.
REFERENCE
Singh DR, Gupta SK, Gupta S. Lord’s procedure: a curative outpatient operation for primary hydrocele. J Indian Med Assoc. 1996;94(4):141–142.
LOWE SYNDROME
DESCRIPTION Also called oculocerebrorenal syndrome, it was 1st described in 1952 as an X-linked recessive disorder manifested by congenital cataracts, hypotonia, developmental delay, poor growth, and renal tubular dysfunction. Proteinuria and aminoaciduria are present by 1 yr of age, with gradual progression of Fanconi syndrome (typically failure to reabsorb water, electrolytes, bicarbonate, glucose, calcium, phosphorus, and small molecules). Polyuria, metabolic acidosis, hypophosphatemia with rickets, hypercalciuria, and sodium and potassium wasting can occur, leading eventually to end stage renal disease (ESRD). Nephrolithiasis has been reported due to the hypercalciuria. Vitamin D supplements and surveillance for nephrolithiasis are recommended.
REFERENCE
Sliman GA, Winters WD, Shaw DW, et al. Hypercalciuria and nephrocalcinosis in the oculocerebrorenal syndrome. J Urol. 1995;153(4):1244–1246.
LUB SYNDROME
DESCRIPTION Very rare, incomplete androgen insensitivity of karyotype XY with testes but ambiguous genitalia. Nonfertile, with elevated testosterone and LH levels, these children are usually raised as female and early gonadectomy and feminizing genitoplasty is performed in infancy. (See Section I: “Disorders of Sexual Development [DSD].”)
REFERENCE
Snyder HM. Management of ambiguous genitalia in the neonate. In: Snyder NM, ed. Urologlic Surgery in Neonates and Young Infants. 19th ed. Philadelphia, PA: Saunders; 1988:346–348.
LYME DISEASE, UROLOGIC CONSIDERATIONS
DESCRIPTION Lyme disease is caused by the spirochete Borrelia burgdorferi and is a multisystem inflammatory disorder. Urinary dysfunction is rarely reported but has been linked to detrusor hyperreflexia or, less commonly, hyporeflexia. Detrusor external sphincter dyssynergia has not been described. The urinary tract may be part of the neuroborreliosis phase or the spirochete may directly invade the urinary tract.
SYNONYMS
• Neuroborreliosis
• Bannwarth syndrome
• Acrodermatitis chronica atrophicans
TREATMENT
• Therapy is aimed at stage of dissemination and symptomatology; 1st-line therapy is doxycycline 100 mg BID or amoxicillin 500 mg QID for 10–15 days; a longer course or IV antibiotics are required for more severe disease.
• Conservative bladder management including clean intermittent catheterization (CIC) guided by urodynamic evaluation.
REFERENCE
Puri BK, Shah M, Julu PO, et al. Urinary bladder detrusor dysfunction symptoms in lyme disease. Int Neurourol J. 2013;17(3):127–129.
LYMPHANGIOGRAM, PEDAL
DESCRIPTION Contrast injection into lymphatic channels on the dorsum of foot to visualize retroperitoneal lymph nodes. This technique has been largely replaced by CT, but it can be used to assess the retroperitoneal lymph nodes in patients with testicular and prostatic cancer. Its major advantage over CT scan is the detection of architectural changes in nonenlarged lymph nodes. It is time-consuming, invasive, does not opacify sentinel nodes, cannot differentiate between malignant and nonmalignant changes, and may cause fibrosis of lymph nodes due to reaction to the contrast medium (Image ).
REFERENCE
Pollack H. Tumors of the testis and testicular adnexa. In: Pollack H, ed. Clinical Urography. Philadelphia, PA: Saunders; 1990:1424–1428.
LYMPHANGIOMA, BLADDER
DESCRIPTION This rare bladder lesion presents with hematuria, and several cases are reported in children. Treatment is by partial cystectomy. The lesion is composed of multiple small cystic cavities filled with proteinaceous material, typical of cavernous lymphangiomas.
REFERENCE
Bolkier M, Ginesin Y, Lichtig C, et al. Lymphangioma of bladder. J Urol. 1983;129(5):1049–1050.
LYMPHANGIOMA, RENAL
DESCRIPTION A rare tumor, with 1/3 occurring in children and 2/3 in adults. The lesion appears as a solitary encapsulated mass with multiple cysts. Microscopy reveals benign endothelial cells with septa, which may contain smooth muscle. If within the renal sinus, the mass may cause obstruction.
REFERENCE
Chaabouni A, Rebai N, Fourati M, et al. Cystic lymphangioma of the kidney: diagnosis and management. Int J Surg Case Rep. 2012;3(12):587–589.
LYMPHANGIOMA, RETROPERITONEAL
DESCRIPTION Lymphangiomas are benign cystic tumors of the lymphatic system. They are rare tumors and retroperitoneal lesions account for only 1% of all lymphangioma lesions. <200 cases have been reported in the literature. They typically present clinically with a palpable abdominal mass, abdominal pain or distention, anorexia, nausea/vomiting, or diarrhea. These lesions can easily be confused with other retroperitoneal cystic tumors, including those arising from the liver, kidney, or pancreas. Surgical excision is generally required for definitive diagnosis and treatment. (See also Section I: “Retroperitoneal Masses and Cysts.”)
REFERENCE
Bhavsar T, Saeed-Vafa D, Harbison S, et al. Retroperitoneal cystic lymphangioma in an adult: A case report and review of the literature. World J Gastrointest Pathophysiol. 2010;1(5):171–176.
LYMPHANGIOMA, SCROTAL
DESCRIPTION Congenital malformations of the intrascrotal lymphatic system, which may form cystic masses. These lymphangiomas are benign tumors, occurring mostly in children. They are found relatively infrequently in the scrotum. Treatment consists of surgical excision; unless completely removed, recurrences are common.
REFERENCE
MacMillan RW, MacDonald BR, Alpern HD. Scrotal lymphangioma. Urology. 1984;23(1):79–80.
LYMPHATIC ASCITES
DESCRIPTION Nonmalignant ascites is the most common form (80–90% ) and can be the result of cardiac, liver, or renal failure. Malignant ascites accounts for 10–20% . Lymphatic ascites can be the result of obstruction of lymphatic vessels or, less frequently, a surgical complication following retroperitoneal surgery or trauma. Persistent lymphatic fluid leakage with ascites has been described following both nephrectomy and retroperitoneal lymph node dissections and other surgical procedures (colorectal, gynecologic). The cisterna chyli (enlarged lymphatic vessel within the lumbar region) is the transition point between chylomicron rich or poor lymphatic fluid. When lymphatic fluid is encountered superior to the cisterna chyli, it is termed “chylous" (milky white appearance due to high cholesterol) and in urology is most often seen associated with retroperitoneal lymph node dissection for testicular cancer. When the fluid is distal to this transition point, the condition is classified as lymphatic (minimal cholesterol, straw-colored or clear fluid) (See Section I: “Chylous Ascites.”) (Image )
REFERENCE
Micha JP, Mendivila AA, Cupp JS, et al. Recurrent lymphatic ascites in a patient cured of cervical carcinoma. Gynecologic Oncology Case Reports. 2012;2(3):105–106.
LYMPHOGRANULOMA VENEREUM
DESCRIPTION Lymphogranuloma venereum (LGV) is a relatively uncommon STI/STD caused by Chlamydia trachomatis (L1, L2, and L3 serovariants). While uncommon in the United States, it is endemic in parts of Africa, India, Southeast Asia, South America, and the Caribbean and is diagnosed more often in men than women. It is also known as lymphogranuloma inguinale, tropical bubo, and Nicolas–Favre disease. Initial infection (after 3 d) is a painless herpetiform lesion on the penis or scrotum in males and rarely presents initial symptoms in females. This is followed by a secondary stage (2–4 wk later) of tender groin lymphadenitis (buboes) and malaise in heterosexual males. Suppurative granulomatous lymphadenitis and matted draining nodes are seen. Genital swelling is common due to obstructed lymphatics. Females and anal receptive homosexual males are more likely to develop pelvic and perianal abscesses with proctocolitis in tertiary disease. Potentially fatal bowel obstruction with perforation if rectal stenosis is severe. The main differential is between syphilis and chancroid. Nucleic acid amplification testing is the diagnostic test of choice; screening for other STI/STD including HIV should be considered. Fluctuant buboes can be aspirated to reduce morbidity.
TREATMENT
Doxycycline is the treatment of choice and erythromycin, sulfisoxazole, and azithromycin are alternatives and should be used for at least 3 wk. Treat contacts within the last 30 d as well.
REFERENCE
MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/000634.htm (Accessed August 24, 2014)
LYMPHOMA, UROLOGIC CONSIDERATIONS
DESCRIPTION Lymphoma can involve any part of the urinary tract, but is more commonly seen in the testicle and kidney:
• Lymphoma represents a common cause of testicular cancer in older men. It may be a local tumor growth or a late manifestation of widespread disease. >50% of testicular tumors in men >60 are lymphomas; these must be differentiated from seminoma. In adults, most are diffuse, large B-cell lymphomas; children can have Burkitt lymphoma involving the testicle.
• Bladder involvement is usually secondary to systemic disease and is present in 13% of patients dying of non-Hodgkin lymphoma. Primary bladder lymphoma occurs almost exclusively in females. Lesions may be sessile or polypoid and should be differentiated from chronic inflammatory bladder involvement, small cell carcinoma, and a rare entity called lymphoma-like carcinoma.
• Prostate lymphoma typically presents in older men, with symptoms of bladder outlet obstruction. PSA is rarely elevated. This is usually a manifestation of systemic disease, with primary prostate disease rare. The differential diagnosis includes chronic prostatitis with follicular hyperplasia, neuroendocrine prostate cancer, and granulomatous prostatitis.
• Adrenal involvement is present in up to 25% dying of systemic disease. The adrenals are a rare primary site of disease, with bilateral, clinical, adrenal involvement in 18% of non-Hodgkin lymphoma and 9% of Hodgkin lymphoma. (See also Section II: “Hodgkin Lymphoma, Urologic Considerations.”)
TREATMENT
• Testicular lymphomas: radical orchiectomy followed by systemic chemotherapy, depending on the extent of the disease. For stage I disease, 5-yr survival is >60%; if advanced, survival at 5 yr is <20%.
• Bladder lymphoma: Treated with radiation. If the bladder site is part of systemic disease, use systemic therapy.
• Prostatic lymphoma: Systemic therapy with TUR is used for obstructive symptoms. A poor prognosis, regardless of primary site; most die in <24 mo.
REFERENCE
Wang Y, Li ZM, Huang JJ, et al. Three prognostic factors influence clinical outcomes of primary testicular lymphoma. Tumour Biol. 2013;34(1):55–63.
LYMPHORETICULAR MALIGNANT NEOPLASM, PENIS
DESCRIPTION Rarely, lymphoreticular malignancies (eg, leukemia) may infiltrate the penis. Primary disease is rare, and a search for systemic disease is mandatory. The most common presentation is priapism, a painful prolonged erection. Treatment involves chemotherapy for primary lesions combined with local low-dose radiation.
REFERENCE
Begun FP, Derus J, Toorkey B, et al. Leukemia of the penis. J Urol. 1989;142(1):123–124.
LYMPHOVASCULAR INVASION (LVI), UROLOGIC CONSIDERATIONS
DESCRIPTION LVI describes an important feature for many aspects of urologic oncology, because it is an adverse prognostic indicator in urothelial carcinoma of the bladder and upper tracts, prostate cancer, and testicular cancer. In upper tract TCC, it has been found to be an independent prognostic factor for disease-specific survival. In noninvasive bladder cancer, it is a relative indication for early cystectomy. In testicular cancer, it is a risk factor for retroperitoneal and/or systemic failure.
REFERENCE
Sheinfeld J, Bosl GJ. Surgery of testicular tumors. In: Wein AJ, et al., eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2012:871–892.
LYNCH SYNDROME
DESCRIPTION An autosomal dominant genetic syndrome caused by mutations in mismatch-repair enzymes, most commonly MSH2 and MLH1. This creates DNA MSI (Microsatellite instability) and increases the risk of colon and endometrial malignancy. An increased risk of upper tract urothelial carcinoma (TCC) is also observed and these cases can be successfully managed with ureteroscopic treatment/surveillance. In addition, these patients are at increased risk of developing bladder lesions as well.
SYNONYMS
• Hereditary nonpolyposis colorectal cancers
• Hereditary site-specific colon cancer
TREATMENT
• Screening for mutation can be performed via genetic testing.
• If screening is positive, surveillance colonoscopy is recommended.
• Netherlands Surveillance Protocol for specific individuals (includes regimented colonoscopies, urine cytologies, upper endoscopy, and US of the endometrium).
REFERENCE
Hubosky SG, Boman BM, Charles S, et al. Ureteroscopic management of upper tract urothelial carcinoma (UTUC) in patients with Lynch Syndrome (hereditary nonpolyposis colorectal cancer syndrome). BJU Int. 2013;112(6):813–819.