kidney & ureter Flashcards
(96 cards)
1
Q
Which kidney can be used for transplantation and why?
A
LEFT KIDNEY
Because Left renal vein is longer than right
2
Q
Anatomical locations of renal arteries?
A
Right renal artery passess behind the IVC
Left renal artery is anterior to the aorta
3
Q
What is the order of renal hilar structures?
A
From Anterior to Posterior, the renal hilar structures are, Renal Vein, Renal Artery and collecting system
(Mnemonic: VAP- vein, artery, pelvis)
4
Q
Arterial supply to the kidney?
A
Renal artery –> Segmental artery –>Interlobar artery –>Arcuate artery –> Interlobular artery –> Afferent artery
5
Q
Renal capsule in relation to other layers in kidney?
A
The renal capsule relates to the other layers in the following order (moving from innermost to outermost):
- renal medulla
- renal cortex
- renal capsule
- perinephric fat (or “perirenal fat”)
- renal fascia(Gerota’s fascia anteriorly and Zuckerkandal fascia posteriorly)
- paranephric fat (or “pararenal fat”)
- peritoneum (anteriorly), and transversalis fascia (posteriorly).
6
Q
What is Renal Collar?
A
- The left renal vein normally passess anterior to the aorta to join IVC
- However sometimes left renal vein may divide and send one limb anterior and one limb posterior to the aorta to reach IVC is called as Renal collar representing persistence of embryological state
7
Q
what is the length of ureter in the adult?
A
generally 24-30cm
8
Q
What are the distinct sites of narrowing in normal ureter?
A
there are 3 distinct sites:
- at ureteropelvic junction
- where the ureter crosses the iliac vessels
- at ureterovesical junction(narrowest part)
9
Q
Can surgeons identify the ureters at laporatomy?
A
YES, because the ureteric wall is muscular and visible contractions or vermiculations, enables the surgeon to identify during laporatomy
10
Q
What are the methods to approach a kidney for nephrectomy?
A
There are 2 common methods to approach kidney for nephrectomy or otherwise:
- The Transperitoneal abdominal approach
- The Retroperitoneal loin approach
11
Q
The retroperitoneal loin approach is preferred method except for 2 conditions . what are they?
A
- malignant tumors
- renal injury (peritoneum is opened to exclude other injuries)
12
Q
Muscles that are cut in loin approach?
A
- Latissimus dorsi
- Serratus posterior-inferior
- 3 lateral muscles of abdominal wall
- External oblique
- Internal oblique
- Transversus abdominis
13
Q
Potter facies is seen in?
A
Seen in Bilateral renal agenesis
14
Q
Features of Potter facies ?
A
- Hypertelorism
- prominent inner canthal fold
- Blunted nose
- recessive chin
- Broad and lower set ears
- limb deformities
15
Q
Unilateral renal agenesis is associated with?
A
- unicornuate or bicornuate uterus and
- septate vagina in females
16
Q
Most common location of ectopic kidney?
A
At thePelvic brim or in the pelvis
17
Q
On which side is renal ectopia is more common?
A
Left side
18
Q
Most common renal fusion abnormality ?
A
HORSESHOE KIDNEY
19
Q
what is Horseshoe kidney?
A
- It is a renal fusion abnormality
- It is because of Fusion at the lower poles by a parenchymatous or fibrous isthmus
20
Q
At what location is kidney trapped in Horseshoe idney?
A
Trapped under the inferior mesenteric artery
21
Q
How is diagnosis of Horseshoe kidney made?
A
Diagnosis is is usually made on intravenous pyelogram(IVP) showing:
- Low lying kidneys(close to vertebral column)
- Hand joining sign
- Flower vase sign
22
Q
What is Hand-joining sign?
A
characteristic orientation of the calyces, directed posterior to each renal pelvis, with lower most calyc pointing caudally or even medially
23
Q
What is Flower vase sign?
A
High insertion of ureter appears to drape over a midline mass
24
Q
What is the management criteria of Aortic aneurysm with horseshoe kidney?
A
Preoperative angiography is essential for the proper evaluation of the renal arteries, as there are multiple aberrant renal arteries arising from aorta
25
what is the most common congenital anomaly of urinary tract?
Duplication of renal pelvis
26
Patients with duplex collecting system have increased incidence of?
- PUJ obstruction
| - uterus didelphys
27
Investigation of duplex collecting system?
- IVP shows the duplication
| - Micturating cysto-urethrogram(MCU) demonstrates the Vesicoureteral reflux(VUR)
28
Treatment for duplex collecting system?
- Lower grade reflux is treated medically and high grade surgically
- Surgery is reserved for upper pole obstruction
- If renal function in one segment is very poor, Heminephrectomy is the most appropriate treatment
29
What is ureterocele?
ureterocele is the ballooning of the distal submucosal ureter into the bladder
- It is thought to be result from congenital atresia of ureteric orifice
30
Diagnosis of ureterocele?
USG: shows hydroureteronephrosis, cyst in bladder
IVP: Typical Adder head or Cobra head Or Spring onion appearance is the diagnostic of ureterocele
MCU: A smooth filling defect is noted in the trigonal area
Cystoscopy: Enlarging and collapsing cyst is noted as urine flows
31
What are the surgical methods included for treatment of ureterocele?
Surgical methods include:
1) Transurethral incision
2) Transurethral un-roofing of the ureterocele in the adult patient
3) Upper pole heminephrectomy and partial ureterectomy with ureterocele decompression
4) Ureteropyelostomy
5) Excision of ureterocele and ureteral reimplantation: done in patient with significant VUR in lower pole moiety and well functioning upper pole moiety
6) Nephroureterectomy( in non-functioning kidney)
32
what is Ureteropyelostomy?
Ureteropyelostomy is an operation that joins the upper pole ureter to the lower pole renal pelvis
33
What is retrocaval ureter?
retrocaval ureter(circumcaval ureter) is an embryologically normal ureter becomes entrapped behind IVC
Ureter deviates medially and passes behind the IVC, winding about crossing in front of it from medial to lateral side, to resume a normal course to bladder
34
Diagnosis of retrocaval ureter?
- High-dose contrast-enhanced computed tomography (CECT) scan of KUB (Kidney, Ureter, Bladder) is Investigation of choice(IOC)
- IVP: 'Reverse J' , "Fish Hook" or "Shepherd crook" deformity are seen.
35
what is the surgical management for retrocaval ureter?
Ureteral division with relocation ureteroureterostomy in cases of obstruction
36
What is congenital PUJ obstruction?
A blockage of the ureter at the junction with the renal pelvis resulting in restriction of urine flow
- It is the most common cause of significant dilation of the collecting system in fetal kidney
37
what are the associated anomalies with congenital PUJ obstruction?
Asoociated anomalies:
- Renal dysplasia
- Multicystic dysplastic kidney
- Renal agenesis
- Vescico- ureteric reflux
- VATER(Vertebral defects, imperforate anus, tracheoesophageal fistula, radial and renal dysplasia)
38
How to diagnose congenital PUJ obstruction?
- Ultrasound:
- IVP: main radiological investigation for congenital PUJ obstruction. but now has been replaced by DTPA scan
- Whitaker test: used to find out obstruction to flow of urine
- Retrograde pyelography: useful to locate the site of obstruction
39
Treatment for congenital PUJ obstruction?
- CONSERVATIVE in children with good renal function without any complication
- SURGICAL- open or endoscopic or laparoscopic technique
40
What are the surgical methods to treat congenital PUJ obstruction?
- Open techniques: Anderson-Hynes Dismembered Pyeloplasty is the most common employed technique
- Endoscopic approaches include:
Endoscopic pyelotomy, Ballon dilatation, Stent placement
41
Gene of ADPKD1 AND ADPKD2 are found on chromosome?
ADPKD 1- chromosome 16p
| ADPKD 2- chromosome 4q
42
What is the clinical presentation of ADPKD:
- Hypertension (most common due to activation of RAAS)
- Mass
- Pain
- Hematuria
- Nocturia( due to impaired concentrating ability)
- Nephrolithiasis
- Infection
- Uremis
43
How to investigate ADPKD?
- USG: shows enlarged kidney with multiple cysts of varying sizes replacing the parenchyma
- IVP: it shows SPIDER LEG APPEARANCE due to stretching of the calyces by the cysts
- CT: CECT is the IOC
- Urine examination: High output of urine, low specific gravity, it may contain traces of albumin
44
Most common cause of death in ADPKD?
Chronic renal failure
45
Management of ADPKD?
- RENAL TRANSPLANTATION is the only definite treatment
- Treatment is mainly aimed to control HTN
- Pain can be relieved by percutaneous aspiration with instillation of sclerosing agent or Rovsing's operation(deroofing of the cyst)
46
What are the anomalies associated with ADPKD?
- Cysts in the liver(most common), spleen, pancreas & ovaries
- Berry's aneurysm
- Mitral valve prolapse
- Colonic diverticulosis
- Congenital hepatic fibrosis
- Aortic root and annulus dilatation
47
Diagnosis of infantile PKD?
IVP: Delayed function with characteristic radial or medullary streaking(SUNBURST PATTERN)
48
What is vesicoureteral reflux(VUR)?
VUR is the retrograde flow of urine from the bladder to ureter and the renal pelvis
(most common urological finding in children)
49
Investigation of VUR?
demonstration of reflux of urine from bladder to upper urinary tract by either contrast voiding cystourethrogram(VCUG) or radionuclide cystogram(RNC)
- VCUG(MCU is the IOC
- (dimercaptosuccinic acid)DMSA scan shows cortical renal scarring
50
Complications of VUR?
- Renal infection(pyelonephritis)
- Renal injury or scarring
- Renin mediated HTN
- Reflux nephropathy
- Renal insufficiency
- ESRD
- Reduced somatic growth
- Morbidity during pregnancy
51
Drug of choice for antibiotic prophylaxis for children upto 6 weeks of age in VUR?
Amoxycillin or Ampicillin
52
Drug of choice for antibiotic prophylaxis for children after 6 weeks of age in VUR?
Trimethoprim-sulfamethoxazole(mostly used)
- Nitrofurantoin(Macrodantin) is another acceptable option for prophylaxis
53
Why TMP-SMX is the prophylaxis DOC after 6 weeks of children?
This is because after 6 weeks, the biliary system of new born becomes mature enough to handle TMP-SMX
54
What are the treatment fundamentals for VUR?
- Medical management is the initial treatment in almost all children (except for Grade 3 & 4, Grade 5)
- Medical management(antibiotic prophylaxis) is continued till reflux resolves
- Pt. is shifted from medical to surgical management, in children with:
* Breakthrough URI(Recurrent UTI despite prophylaxis)
* Development of new renal scars
* Failure of reflux to resolve
- NIGHT TIME DOSING of antibiotic prophylaxis in toilet trained children is most effective because it precedes the longest peroid of urinary retention, when infection is most likely to develop
55
What are the surgical options for VUR?
- Ureterovesicoplasty
- Ureteric reimplantation
- STING (Subureteric transurethral injection of teflon paste)
56
what is the mean age for reflux resolution in VUR?
6 to 7 years
57
Most common type and cause of renal injury?
Blunt injury
road traffic accident
58
what is the best indicator of traumatic urinary system injury?
Hematuria
59
what are the clinical features for renal trauma?
- Evidence of laceration or bruising of overlying skin of abdominal wall
- Local pain and tenderness is always present
- Associated fracture of lower ribs or vertebral bodies may be present
- Hematuria
- Severe delayed Hematuria
- Meteorism
60
What is Meteorism?
This is abdominal distention(after 24-48hrs of injury) probably due to retroperitoneal hematoma compressing the splanchnic nerves
61
what is severe delayed hematuria?
This can occure between 3rd day and the 3rd week, probably due to dislodgement clot
62
Investigation of renal trauma?
- CECT is the IOC for renal injuries
- IVP
- Angigraphy is used to define arterial injuries suspected on CT or to localize and contral arterial bleeding by embolization
63
what are the early complications of renal trauma?
- hemorrhage(retroperitoneal bleeding)
- Urinary extravasation and Urinoma
- Delayed bleeding
- Perinephric abscess
64
what are the late complications of renal trauma?
- HTN
- Hydronephrosis
- AV fistula
- Calculus
- Pyelonephritis
65
what type of approach is required for renal exploration?
Transperitoneal(transabdominal) approach
66
what are the operative options in renal trauma for following conditions:
1. Small laceration?
2. Laceration confined to one pole of kidney?
3. when kidney is severely ruptured or avulsed from its pedicle?
1. sutured
2. partial nephrectomy
3. nephrectomy
67
Most common type of renal calculus?
Calcium oxalate calculus
68
Risk Factors for renal calculus?
```
Dehydration
Infection
Urine pH changes
Urinary tract obstruction
Immobilization
Metabolic factors, such as hypercalciuria and decreased magnesium levels
Family member with a history of renal calculi
Certain medications, such as indinavir
High intake of calcium supplement
```
69
What are phosphate calculus?
A phosphate calculus (calcium phosphate often with ammonium magnesium phosphate(struvite)) is
- smooth and dirty white
- It grows in alkaline urine, especially with proteus infection which split urea to ammonia
- The calculus may enlarge to fill most of the collecting system, forming a stag-horn calculus
70
what are uric acid and urate calculus?
- These are RADOILUSCENT
- Form in acidic urine
- seeon in GOUT, myeloproliferative disorders or Lesch-Nehan syndrome(hyperurecemia)
- Most responsive to LITHOTRIPSY
71
what are cystein stones/calculus?
- uncommon, seen in cystinuria
- appear only in acidic urine
- they are pink to yellow when first removed but they change colour to greenish blue when exposed to air
- they are radio-opaque and extremely hard stones
- relatively resistant to fragmentation by ESWL(Extracorporeal shock wave lithotripsy)
72
what are xanthine calculi?
- they are radioluscent
| - seen in xanthinuria(due to congenital deficiency of xanthine oxidase)
73
what are indinavir calculi?
Indinavir is a protease inhibitor used in AIDS paients, it results in calculi in 6% pt.
- they are radioluscent
74
what are silicate stones?
- associated with long term use of antacids containing silica
75
what are Triamterene stones?
- associated with antihypertensive medications containing triamterene
- they are radioluscent
76
Name the Radioluscent stones?
- Uric acid calculi
- Xanthine calculi
- Indinavir calculi
- Triamterene calculi
(they all are radioluscent on xrays. All these stones except Indinavir are not radioluscent on CT scan where they all appear radioopaque)
77
what are the stones formed in acidic urine?
Calcium oxalate, Uric acid, Cysteine
78
what are the stones formed in alkaline urine?
Struvite stones
79
Identify the position of the stone by site of pain mentioned below:
1. Pain radiates to testicles
2. Pain is referred to Mc Burneys point on the right side resenbling appendicitis and on left side stimulates diverticulitis
3. Pain is referred to inner side of thigh, groin
4. Strangury(painful and fruitless desire to micturate)
1. At PUJ or upper ureter
2. At middle of the ureter(i.e., at crossing of gonadal vessels and ureter)
3. At lower ureter or at pelvic brim
4. In the intramural ureter
80
What is Dietel's crisis?
- After an attack of acute renal pain, a swelling in the loin is found
- Some hours later, following the passage of large amounts of urine , the pain is relieved and swelling disappeatrs
- This is caused due to intermittent renal pelvic obstruction due to calculus
81
Investigation of renal colic?
- USG is the 1st investigation for renal colic
- Gold standard investigation and IOC for renal colic: Non contratst CT scan
- X-ray KUB: -90% are radioopaque
- IVU will establish the presence and position of calculus and function of other kidney
82
DOC for ureteric colic?
DICLOFENAC
83
what are the Indications of conservative treatment(for 4 -6weeks)?
- single stone ≤ 5mm
- stone in lower third of ureter
- ureter is undilated
- evidence of downward movement
84
what does conservative management/observations include renal calculi?
- most ureteral calculi pass spontaneously and do not require any surgical intervention
- Most can be safely observed until they pass
- Medical expulsive therapy facilitate spontaneous passage of ureteral stones. it consists of alpha blocker+ NSAID+/- low dose steroids
85
Indications for surgical removal of ureteric calculus?
- stone is too large to pass spontaneously
- urine is infected
- repeated attacks of pain and stone is not moving
- stone is enlarging
- stone is causing complete obstruction
- stone is obstructing solitary kidney or there is a bilateral obstructions
86
what are the options for surgical interventions?
- Extracorporeal shock wave lithotripsy(ESWL)
- Percutaneous nephrolithotomy(PCNL)
- Ureteroscopy(URS)
- Open/Laproscopic stone surgery such as Pyelolithotomy, Nephrolothotomy - rarely used treatment modality
87
Treatment decision by calculus size/type?
1. stone <5mm
2. stone ≤2cm
3. stone >2cm
4. Stag horn calculi
1. Conservative
2. ESWL
3. PCNL
4. PCNL followed by ESWL
88
what are the Absolute contraindications of ESWL?
- Uncorrected bleeding disorder
| - Pregnancy
89
what are the Relative contraindications of ESWL?
- UTI
- Urinary tract obstruction distal to stone
- Cardiac pacemaker
- Severe orthopedic deformity(it is contraindication only if it prevents proper positioning of stone at F2 focal point)
- Severe renal failure
- Cysteine and calcium oxalate monohydrate stones( because ESWL is not effective fragmenting it)
- weight greater than 300pounds
- lower ureteral stones in women of child bearing age
90
Indications of PCNL?
- Large stone(>2cm), stag horn calculus
- other modalities failure( ESWL or URS failure)
- Lower pole calyceal stone
- Difficult(hard) stones for ESWL : Cysteine, calcium oxalate monohydrate
91
complications of PCNL?
- Bleeding(MC)
- Injury to other viscera like pleura, colon, spleen
- Hydrothorax
- Urinary extravasation
- Retained fragments
- Sepsis
92
What type of approach is preferred in PCNL and why?
The posterior approach is preferred, through the posterior calyx rather than into the renal pelvis, to avoid injury to the posterior branches of renal artery, which are closely associated with renal pelvis
93
Most common treatment of choice for proximal ureteric calculi?
- ESWL(MC)
| - Ureteroscopy acess is also useful in case of failed ESWL
94
Most common treatment of choice for middle and distal ureteric calculi?
Ureteroscopy
95
what are the indications for open stone surgery?
- Whole of the pelvicalyceal system packed with a stag horn calculus
- Morbid obesity: these patients are poor candidates for ESWL/PCNL
- Anatomical abnormality requiring open operative intervention eg: pelviureteric junction obstruction(PUJO)
96
what is DJ stent?
- For HYDROURETERONEPHROSIS, the drianage procedure of choice in emergent situations is cytoscopy with placement of internalized double 'J' ureteral stent.
- This procedure has the advantage of being a completely drainage system
