Fundamentals of Upper Urinary Tract Drainage Flashcards Preview

Anatomy > Fundamentals of Upper Urinary Tract Drainage > Flashcards

Flashcards in Fundamentals of Upper Urinary Tract Drainage Deck (36)
Loading flashcards...
1

The renal parenchyma is composed of the cortex and the medulla. The cortex, outermost, contains the __ and ___. The more interior medulla contains the ___. These are inverted cones (the base of which is superficial and the apex is deep) that comprise the loops of Henle and the collecting ducts, which coalesce at the apex of the pyramid into papillary ducts that open on the surface of the renal papillae. There are approximately___ draining into each papilla. The columns of Bertin are ____ that surround the renal pyramids except at their ____

The renal parenchyma is composed of the cortex and the medulla. The cortex, outermost, contains the glomeruli and proximal and distal convoluted tubules. The more interior medulla contains the renal pyramids. These are inverted cones (the base of which is superficial and the apex is deep) that comprise the loops of Henle and the collecting ducts, which coalesce at the apex of the pyramid into papillary ducts that open on the surface of the renal papillae. There are approximately 20 papillary ducts draining into each papilla. The columns of Bertin are invaginations of cortical tissue that surround the renal pyramids except at their apices.

2

bords of lumbar notch

It is bounded superiorly by the latissimus dorsi muscle and the 12th rib, medially by the sacrospinalis and quadratus lumborum muscles, laterally by the transversus abdominis and external oblique muscles, and inferiorly by the internal oblique muscle

3

The American Urological Association (AUA) does not recommend/recommends periprocedural antimicrobial prophylaxis for all cases of percutaneous renal surger

The American Urological Association (AUA) recommends periprocedural antimicrobial prophylaxis for all cases of percutaneous renal surger

4

except at the upper poles where the diaphragm is posterior the pleura can be violated during percutaneous entry into the upper pole of the kidney. This risk is greater with more cephalad access. The lung is above the ___, so direct lung injury is unlikely unless the ____is used as the entry site.

except at the upper poles where the diaphragm is posterior (Fig. 12.2). The pleura can be violated during percutaneous entry into the upper pole of the kidney. This risk is greater with more cephalad access. The lung is above the 11th rib, so direct lung injury is unlikely unless the 10th intercostal space (superior to the 11th rib) is used as the entry site.

5

the ascending and descending colon can be lateral or even posterior to the right and left kidneys, respectively. The apposition of the colon to the kidney varies with location; it is greatest on the ___and at the ___

the ascending and descending colon can be lateral or even posterior to the right and left kidneys, respectively. The apposition of the colon to the kidney varies with location; it is greatest on the left side and at the lower pole

6

most calyces of the____ are suitable for percutaneous access from the posterior approach, whereas care must be taken to select a ___ in the middle and lower groups

most calyces of the upper pole are suitable for percutaneous access from the posterior approach, whereas care must be taken to select a posterior minor calyx in the middle and lower groups

7

The potential for arterial injury is least in Brödel’s line, an ____ approximately at the____ of the kidney, extending from the____ of the kidney (limited by the circulation of the apical anterior segmental artery) to the ___ of the kidney (limited by the circulation of the lower anterior segmental artery)

The potential for arterial injury is least in Brödel’s line, an avascular plane approximately at the lateral margin of the kidney, extending from the superior apex of the kidney (limited by the circulation of the apical anterior segmental artery) to the lower pole of the kidney (limited by the circulation of the lower anterior segmental artery)

8

T/F

evidence suggests that when the antimicrobial is being administered only for prophylaxis (i.e., not treatment of known or presumed infection), immediate perioperative treatment for percutaneous nephrolithotomy (24 hours or less) is just as effective as a longer course and is therefore preferred

true

9

before undertaking percutaneous renal access. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, and anticoagulants, with few exceptions, should be discontinued before planned surgery as follows: aspirin, ___ week; warfarin, ____ week; clopidogrel, ___ days; and NSAIDs, ___

efore undertaking percutaneous renal access. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, and anticoagulants, with few exceptions, should be discontinued before planned surgery as follows: aspirin, 1 week; warfarin, 1 week; clopidogrel, 5 days; and NSAIDs, 3 to 5 days

10

Access above the___ is associated with a high incidence of pleural violation and lung injury and should be avoided unless absolutely necessary.

10th

11

The lumbar notch, also known as the __ or __ lumbar triangle, has been reported to be a reliable landmark for blind percutaneous renal access

The lumbar notch, also known as the superior lumbar triangle or Grynfeltt lumbar triangle, has been reported to be a reliable landmark for blind percutaneous renal access

12

If there is noticeable bleeding from the tract after sheath removal following an otherwise unremarkable procedure, this suggests bleeding from ___. Hemostatic maneuvers such as___ or placement of hemostatic material can be considered, but in general the best management is ____

If there is noticeable bleeding from the tract after sheath removal following an otherwise unremarkable procedure, this suggests bleeding from intraparenchymal vessels. Hemostatic maneuvers such as cauterization or placement of hemostatic material can be considered, but in general the best management is to insert and occlude a nephrostomy tube, apply pressure to the incision, and let the collecting system clot of

13

Delayed hemorrhage is usually caused by __ or arterial __, with the latter being more common, tx

Delayed hemorrhage is usually caused by arteriovenous fistulas or arterial pseudoaneurysms, with the latter being more common

Both arteriovenous fistulae and pseudoaneurysms are treated with selective angioembolization

14

Renal pelvic perforation is usually recognized ___. The ___ is a usual sign if the perforation is not visualized directly at first.

Renal pelvic perforation is usually recognized intraoperatively . Collapse of a previously distended renal pelvis is a usual sign if the perforation is not visualized directly at first.

15

___ is a direct and persistent communication between the intrarenal collecting system and the intrathoracic cavity

Nephropleural fistula (urinothorax) is a direct and persistent communication between the intrarenal collecting system and the intrathoracic cavity

16

___ should be the irrigant for percutaneous renal surgery, with the exception of___ when monopolar electrocautery is used. Irrigation with ____ during percutaneous renal surgery risks intravascular hemolysis, which can be fatal

Normal saline should be the irrigant for percutaneous renal surgery, with the exception of glycine or similar nonelectrolytic isotonic fluids when monopolar electrocautery is used. Irrigation with water during percutaneous renal surgery risks intravascular hemolysis, which can be fatal

17

Most patients with fever after percutaneous nephrolithotomy, assuming appropriate antimicrobial prophylaxis, do not have infection  Rather, the majority suffer from ___, a nonspecific immune response defined by hyperthermia/hypothermia, leukocytosis/leukopenia, tachycardia, and tachypnea, which can be caused by either infectious or noninfectious insults. Self-limited fever after percutaneous interventions without associated hemodynamic compromise can be managed ___

Most patients with fever after percutaneous nephrolithotomy, assuming appropriate antimicrobial prophylaxis, do not have infection (Cadeddu et al., 1998). Rather, the majority suffer from systemic inflammatory response syndrome (SIRS), a nonspecific immune response defined by hyperthermia/hypothermia, leukocytosis/leukopenia, tachycardia, and tachypnea, which can be caused by either infectious or noninfectious insults. Self-limited fever after percutaneous interventions without associated hemodynamic compromise can often be managed expectantly. Indeed, most patients in this setting can be routinely discharged without intervention or risk for unplanned readmission

18

If ___  is aspirated upon initial percutaneous entry to the upper urinary tract, the safest measure is to ___ and leave a ___

If pus is aspirated upon initial percutaneous entry to the upper urinary tract, the safest measure is to abort the procedure and leave a nephrostomy tube for drainage.

19

When there is renal loss after percutaneous renal surgery, it usually is a result of__ or the ___

When there is renal loss after percutaneous renal surgery, it usually is a result of disastrous vascular injury or the angioembolization used to treat hemorrhage.

20

Percutaneous nephrostomy is not indicated for: a. instillation of intracavitary topical therapy for urothelial carcinoma. b. Whitaker test. c. management of fungal bezoars. d. urinary retention. e. ureteral injury. 2. Relative to retrograde

d. Urinary retention. Obstruction of the lower urinary tract is best treated by drainage of the bladder rather than the kidney, unless secondary obstruction of the upper tract has developed that is refractory to vesical drainage. The other indications are appropriate ones for percutaneous nephrostomy.

21

Relative to retrograde ureteral stent placement, percutaneous nephrostomy

: a. has a lower success rate. b. requires less anesthesia. c. is preferred in cases of ureteral obstruction owing to malignancy. d. is less commonly complicated by bacteriuria after indwelling for 1 week. e. is associated with worse health-related quality-of-life scores.

b. Requires less anesthesia. Percutaneous nephrostomy can be done under local anesthesia, as opposed to retrograde ureteral stent placement, which usually requires at least intravenous sedation, and commonly general or regional anesthesia. Percutaneous nephrostomy has a greater initial success rate than retrograde ureteral stent placement, at least when the collecting system is dilated. Percutaneous nephrostomy is commonly associated with bacteriuria and has health-related quality-of-life scores that are equivalent to those associated with retrograde ureteral stent placement. Ureteral stents provide satisfactory drainage in most cases of ureteral obstruction owing to malignancy

22

Which of the following is correct regarding the orientation of the kidney?

a. The right kidney is slightly cephalad to the left kidney. b. The longitudinal axis is 45 degrees from vertical, with the lower pole lateral to the upper pole. c. The longitudinal axis is 45 degrees from vertical, with the lower pole anterior to the upper pole. d. The apposition of the colon to the kidney is greatest on the left side at the upper pole. e. Immediately posterior to the kidneys are the quadratus lumborum muscle, the psoas muscle, and the diaphragm.

e. Immediately posterior to the kidneys are the quadratus lumborum muscle, the psoas muscle, and the diaphragm. The upper poles are anterior to attachments of the diaphragm. It is the left kidney that is slightly cephalad to the right one. The second two statements are correct, except that the angulation is 30 degrees rather than 45 degrees. The apposition of the colon to the kidney varies with location; it is greatest on the left side but at the lower rather than upper pole.

23

Which of the following is correct regarding the intrarenal collecting system?

a. Paired anterior and posterior calyces enter the infundibula approximately 90 degrees from each other.

b. Compound calyces are most common in the lower pole c. Most kidneys have three distinct infundibula: the upper, middle, and lower.

d. There are 8 to 16 minor calyces.

e. There is a consistent relationship between anterior and posterior calyces and their medial-lateral position on anteriorposterior radiography

a. Paired anterior and posterior calyces enter the infundibula approximately 90 degrees from each other. The paired anterior and posterior calyces enter approximately 90 degrees from each other. Although compound calyces are common in the lower pole, they are almost always present in the upper pole. In approximately two-thirds of kidneys, there are only two major calyceal systems (upper and lower). There are 5 to 14 minor calyces in each kidney. Because variation is considerable, the lateral-medial orientation of the calyces on anteroposterior radiography cannot be used to reliably determine which calyces are posterior.

24

To reduce the risk of infectious complications from percutaneous renal surgery: a. all patients should receive prophylactic antimicrobials. b. urine cultures should be obtained on all patients. c. urine must be sterile before the procedure. d. gentamicin is an acceptable single agent for antimicrobial prophylaxis.

a. All patients should receive prophylactic antimicrobials. The American Urological Association recommends periprocedural antimicrobial prophylaxis for all cases of percutaneous renal surgery. Urine cultures are considered standard only in patients where bacteriuria is likely; in other cases a screening urinalysis likely is adequate, with urine culture when the urinalysis is suspicious. The urine cannot be sterilized in some patients, especially in the presence of an externalized urinary catheter or an infected calculus, and the goal in these situations is only to suppress the bacterial count before intervention. Aminoglycosides (e.g., gentamicin) are acceptable for antimicrobial prophylaxis when combined with another agent. Ampicillin/sulbactam, first- and second-generation cephalosporins, and fluoroquinolones are acceptable single agents for antimicrobial prophylaxis

25

which of the following have NOT been demonstrated in randomized controlled clinical trials to reduce pain associated with percutaneous renal access? a. Tract infiltration with local anesthetic b. Intercostal nerve block c. Thoracic paravertebral block d. Balloon dilation compared with semirigid plastic dilation of the access tract e. Smaller, compared with larger, caliber postprocedure nephrostomy tubes

8. d. Balloon dilation compared with semirigid plastic dilation of the access tract. There is no evidence that balloon dilation is associated with less pain compared with semirigid plastic dilation of the access tract. All of the other maneuvers have been demonstrated in randomized controlled clinical trials to reduce pain associated with percutaneous renal access.

26

The “triangulation” technique for fluoroscopic percutaneous renal access:

a. increases radiation exposure to the operator’s hands compared with the “eye-of-the-needle” technique. b. cannot be performed in malrotated kidneys. c. is not as dependent on retrograde assistance as the “eye-of-theneedle” technique. d. is less suitable than the “eye-of-the-needle” technique in morbidly obese patients. e. continuously monitors depth of needle penetration

Continuously monitors depth of needle penetration. The “triangulation” technique monitors depth of needle placement in all fluoroscopic views, whereas the “eye-of-the-needle” technique assesses depth only at the final step. If the fluoroscopy field is collimated down and the needle is held with a hemostat, sponge forceps, or purpose-built needle holder, then radiation exposure to the operator’s hands can be avoided with both techniques. Retrograde assistance is useful with any fluoroscopic percutaneous renal access, and both techniques are more difficult in morbidly obese patients

27

A postoperative nephrostomy tube: a. offers greater assurance of upper urinary tract drainage than an internal ureteral stent. b. should be placed in the dilated access site. c. does not maintain the percutaneous access tract unless >18 Fr. d. reduces postoperative bleeding. e. is associated with pain unrelated to tube diameter.

A. Offers greater assurance of upper urinary tract drainage than an internal ureteral stent. Drainage of upper urinary tract after percutaneous renal surgery is adequate with an internal ureteral stent in most cases (or with no tube at all in selected cases), but when hemorrhage occurs, the larger caliber of a nephrostomy tube provides better drainage of the upper urinary tract collecting system than an internal ureteral stent. The nephrostomy tube does not have to be placed in the dilated access site (i.e., it can be placed at a new site), although that is common practice. Although redilation may be required, any external nephrostomy tube maintains the percutaneous access tract. There is actually less hemorrhage when a postoperative nephrostomy tube is omitted. Most studies suggest that the pain associated with nephrostomy tubes is related to tube diameter, with smaller-caliber tubes causing less pain

28

A small-caliber (8 to 18 Fr) compared with a large-caliber (20 to 24 Fr) nephrostomy tube after percutaneous renal surgery is associated with: a. equivalent pain. b. more urinary leakage. c. less postprocedure blood loss. d. less need for removal in the radiology suite. e. earlier hospital discharge.

d. Less need for removal in the radiology suite. The removal of larger tubes occasionally can be followed by immediate hemorrhage; this is rare with smaller tubes. Therefore large-caliber nephrostomy tubes should be removed in a radiology suite where there is the opportunity for immediate replacement of the tube. Small-caliber tubes can be removed safely at the bedside after a period of clamping to assess clinically for distal ureteral obstruction. A number of studies have compared the impact of nephrostomy tube diameter after percutaneous renal surgery. Only one study found no benefit to the smaller tube. Otherwise, consistent advantages of the small-caliber tubes were less pain, less urinary leakage, and no change in postprocedure blood loss. There is no consistent evidence that small-caliber tubes are associated with shorter duration of hospitalization compared with large-caliber tubes.

29

compared with internal ureteral stents after percutaneous renal surgery, nephrostomy tubes are associated with:

a. reduced need for a second procedure for removal. b. greater technical success rate. c. greater narcotic use. d. fewer complications. e. less urinary leakage from skin entry site.

4. c. Greater narcotic use. Most randomized controlled trials comparing internal ureteral stents to large-caliber nephrostomy tubes after percutaneous renal surgery have shown reduced narcotic use in the stented patients. The difference is less significant when a small-caliber nephrostomy tube is used. Depending on physician preference, both internal ureteral stents (if attached to a string that exits via the flank) and small-caliber nephrostomy tubes can be removed at the bedside. Randomized controlled trials comparing internal ureteral stents to nephrostomy tubes have not revealed any difference in technical success rates, complication rates, or incidence of urinary leakage from the skin entry site.

30

Following an unremarkable percutaneous nephrolithotomy, there is nonpulsatile bleeding from the tract when the sheath is removed around a 12-Fr nephrostomy tube. The next step is: a. replace the nephrostomy tube with an 18-Fr Malecot catheter. b. replace the nephrostomy tube with a ureteral stent and suture the skin. c. irrigate the nephrostomy tube. d. occlude the nephrostomy tube and apply pressure to the incision. e. replace the nephrostomy tube with a Kaye nephrostomy tamponade balloon.

d