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X. MRCS: Anatomy > Urinary Tract > Flashcards

Urinary Tract Flashcards

(65 cards)

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1
Q

Kidneys: anatomical position

A

Retroperitoneal
Typically T12 - L3
Adrenal glands immediately superior

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2
Q

Kidneys: Layers

A 
Superficial to deep
Pararenal fat
Renal fascia (Gerota's fascia)
Perirenal fat
Renal capsule
Kidney
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3
Q

Kidney: parenchyma areas

A

Cortex (outer)

Medulla (inner)

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4
Q

Kidney: Organisation of parenchyma

A

Cortex extends into medulla, dividing it into triangular shapes: renal pyramids
Apex of perms is called renal papilla
Minor calyx collects urine from pyramids and merge to form major calyx.
Major calices drain into renal pelvis then into the ureter.

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5
Q

Kidney: arterial supply

A

Renal arteries (paired branches of aorta at L1, immediately distal to origin of SMA)
Right renal artery passes IVC posteriorly
Renal artery divides into anterior (75%) and posterior (25%) division. Supply 5 segmental arteries.
Segmental –>
interlobar arteries –>
Arcuate arteries –>
Interlobular arteries –>
Afferent arterioles –>
Glomerulus –>
Efferent arterioles
Peritubular network (supplies nephron)

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6
Q

Kidney: venous drainage

A

Left and right renal veins
Leave hilum anterior to renal artery
Drain into IVC
Left renal vein is anterior to abdominal aorta

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7
Q

Kidney: lymphatic drainage

A

Lateral aortic (para-aortic) lymph nodes

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8
Q

Ureters: anatomical course

A

Arise from renal pelvis at ureteropelvic junction
Descend through abdomen along anterior surface of posts major.
Retroperitoneal.
At SI joints, ureters cross pelvic brim entering pelvic cavity.
Cross bifurcation of common iliac.
Travel down pelvic wall at level of ischial spines. Turn anteromedially.
Pierce lateral aspect of bladder in oblique plane.

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9
Q

Ureters: blood supply

A

Abdominal: renal artery, testicular/ovarian artery, ureteral branches (direct of abdominal aorta)
Pelvic: superior and inferior vesical arteries

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10
Q

Ureters: venous drainage

A

Renal vein, testicular/ovarian vein, ureteral vein, superior and inferior vesical veins

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11
Q

Ureters: nerve supply

A

Renal, testicular/ovarian and hypogastric plexuses

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12
Q

Ureters: narrowest points

A

Uretopelvic junction
Pelvic brim
Entrance of ureter to bladder

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13
Q

Bladder: functions

A

Temporary storage of urine

Assists in expulsion of urine

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14
Q

Bladder: shape

A

Apex: superior
Body: between apex and fundus
Fundus (or base): posterior
Neck: convergence of fundus, continuous with urethra

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15
Q

Bladder: Blood supply

A

Superior vesical artery, branch if internal iliac
In males, supplemented by inferior vesical artery.
In females, vaginal artery.
Obturator and inferior gluteal may also contribute branches

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16
Q

Bladder: venous drainage

A

Vesical venous plexus. Empties into internal iliac vein.

In males, vesical plexus is in continuity at the retropubic space with prostate venous plexus (plexus of Santorini)

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17
Q

Bladder: lymphatic drainage

A

Superolateral: external iliac lymph nodes

Neck, fundus: internal iliac, sacral, common iliac nodes

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18
Q

Bladder: innervation

A

Sympathetic: hypogastric nerve (T12-L2). Causes relaxation of detrusor muscle, promoting urine retention
Parasympathetic: pelvic nerve (S2-S4). Causes contraction of detrusor muscle, stimulating micturation
Somatic: pudenal nerve (S2-4). External urethral sphincter giving voluntary control of micturation

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19
Q

Bladder: wall and musculature

A 
internal to external:
Transitional epithelium
Laminar propria
Submucosa
Detrusor muscle
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20
Q

Phases of micturition

A

Storage phase

Voiding phase

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21
Q

Storage phase of micturition

A 
Controlled by continence centres in pons which control continuance centres in spinal cord. 
Storage requires: relaxation of detrusor muscle, contraction of internal & external urethral sphincters
Sympathetic nuclei (T12-L2) --> hypogastric nerve --> detrusor & IUS
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22
Q

Voiding phase of micturition

A

Parasympathetic control
Afferent signals from bladder ascend to pontine micturition centre and cerebrum.
Upon voluntary decision to micturate, neurones of pontine micturition centre fire, exciting sacral preganglionic neurones.
Subsequent parasympathetic stimulation to pelvic nerve (S2-4) to muscarinic receptors on detrusor muscle, causing contraction.
Pontine micturition centre also inhibits Onuf’s nucleus reducing sympathetic simulation to IUS, causing relaxation.
Conscious reduction in voluntary contraction of EUS

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23
Q

Causes of urinary retention

A 
BPH
Nerve dysfunction
Infection
Constipation
Drugs (anticholinergics, antidepressants, opioids)
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24
Q

Urethra: parts

A

Prostatic urethra
Membranous urethra
Penile (bulbous) urethra

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25
Prostatic urethra
Begins as continuation of bladder and neck Passes through prostate gland Receives ejaculatory ducts and prostatic ducts Widest part of urethra
26
Membranous urethra
Passes through pelvic floor and deep perineal pouch Surrounded by external urethral sphincter Narrowest and least dilatable portion of urethra
27
Penile urethra
Passes through bulb and corpus spongiosum of penis Ends at external urethral orifice (the meatus) Receives bulbourethral glands proximally
28
Urethra: blood supply
Prostatic: inferior vesical artery (branch of internal iliac) Membranous: bulbourethral artery (branch of internal pudendal artery) Penile: branches of internal pudendal artery Female: internal pudendal artery
29
Urethra: innervation
Prostatic plexus (mix of sympathetic, parasympathetic, visceral afferent) Female: Pudenal nerve
30
Urethra: Lymphatic drainage
Prostatic/mebranous: obturator and internal iliac nodes Penile: deep and superficial inguinal nodes Female: internal iliac nodes, superficial inguinal lymph nodes
31
Zones of the prostate
McNeal's zones Central zone Transitional zone Peripheral zone
32
Central zone of the prostate
Surrounds ejaculatory ducts 25% of normal prostate Glands drain obliquely into urethra (relatively immune to urine reflux)
33
Transitional zone of the prostate
Located centrally, surrounds the urethra 5-10% of normal prostate volume Typically undergo BPH
34
Peripheral zone of prostate
Main body of gland: 65% | Ducts vertically drain into urethra, allowing urine reflux
35
Fibromuscular storm of prostate
Situated anterior to gland | Merges with tissue of urogenital diaphragm
36
Blood supply to prostate
Prostatic arteries, branches of internal iliac
37
Venous drainage of prostate gland
Prostatic venous plexus, draining into internal iliac veins
38
Innervation to the prostate
Inferior hypogastric plexus
39
Anatomical relations of the prostate
Neurovascular bundle to penis (can be damaged in prostatectomy)
40
Kidney stones: composition
``` Calcium oxalate (35%) Calcium phosphate (10%) Mixed oxalate/phosphate (35%) Struvite (magnesium ammonium phosphate) Urate (only radiolucent stones) Cystine stones ```
41
Struvite stones
Large soft stones Commonest cause of "stag horn calculi" Associated with UTI
42
Pathophysiology of stone formation
Over-saturation of urine Urate stones: high levels of purines (from red meat diet or myeloproliferative disorders) Cystine stones: associated with homocystinuria
43
Criteria for Inpatient management of stones
Post-obstructive AKI Uncontrollable pain Evidence of infected stones Large stones >5mm
44
Management of renal calculi
``` Evidence of obstruction/infection: stent/nephrostomy Small stones (<2mm): Extracorporeal shock wave lithotripsy (ESWL), CIs: pregnancy/near bony landmark Large stones: Percutanous nephrolithotomy ```
45
Bladder stones
Urine stasis. Commonly seen in chronic urine retainers. | Increases risk for SCC bladder.
46
Renal cancer: types
Renal cell carcinoma (85%) Transitional cell carcinoma Nephroblastoma (Wilm's tumour, paeds) SCC (secondary to chronic inflammation, e.g. stones/UTI)
47
Renal cell carcinoma, pathology, spread and RFs
Adenocarcinoma of renal cortex, predominantly from proximal tubule. Most commonly in upper pole of kidney Spread: local invasion (adrenal, renal vein, IVC), lymphatic (pre-aortic/hilar), haematogenous (bones, liver, brain, lung) RFs: smoking. Industrial (cadmium, lead, aromatic hydrocarbons), dialysis, HTN, obesity, polycystic kidney, horseshoe kidney
48
Renal cell carcinoma, clinical
Haematuria. Non-specific Sx. Flank mass. Left varicocele (compression of left testicular vein) Paraneoplastic: polycythemia (EPO), hypercalcaemia (PTH), HTN (renin) Sx of metastasis, 25% have mets at diagnosis Ix: US for haematuria, CT with IV contrast.
49
Renal cell carcinoma
Localised disease: Partial/radical nephrectomy | Metastatic disease: immunotherapy, biological agents (Sunitinib, Pazopanib: tyrosine kinase inhibitors)
50
Bladder cancer: types
Transitional cell carcinoma (80-90%) Squamous cell carcinoma Adenocarcinoma Sarcoma
51
Bladder cancer: classifications
Non-muscle invasive bladder cancer Muscle-invasive bladder cancer Locally advanced Metastatic
52
Layers of the bladder wall
``` Inner to outer: Transitional epithelium (urothelium) Lamina propria Muscularis propria Fatty connective tissue ```
53
Bladder cancer: risk factors
``` Smoking Age Aromatic hydrocarbons (industrial dyes/rubbers) Schistosomiasis (SCC) Radiation to pelvis ```
54
Bladder cancer: investigations
``` Haematuria: BP Bloods: U&Es, glucose, FBC, PSA, >50: 2WW, CT urogram +/- contrast <50 USS ``` Cystoscopy Rigid cystoscopy & biopsy CT staging (muscle invasive)
55
Bladder cancer: management
NMI: resection via TURBT +/- adjuvant intravesical therapy (Bacille Calmette-Guerin). If high risk disease: radical cystectomy MI: Radical cystectomy + urinary diversion (ill conduit/bladder recon), neoadjuvant chemo. Locally advanced/metastatic: chemo
56
Benign prostatic hyperplasia (BPH): risk factors
Age FH Black African/Caribbean ethnicity Obesity
57
BPH: clinical features
LUTS: voiding symptoms (hesitancy, weak stream, terminal dribbling, or incomplete emptying) DRE: firm, smooth, symmetrical prostate
58
BPH: medical management
a-adrenoreceptor antagonist (a-blocker): alfuzosin, doxazosin, tamsulosin or terazosin. SEs: postural hypotension, retrograde ejaculation, floppy iris syndrome 5α-reductase inhibitors: Finasteride SEs: can take 6months to have effect Anti-cholinergic: Oxybutynin
59
BPH: surgical management
If refractory to medical management or develop complications of BPH (high pressure retention) (Minimally invasive) TURP (complications: TURP syndrome, haemorrhage, sexual dysfunction, retrograde ejaculation, urethral stricture)
60
TURP Syndrome
Hypoosmolar irrigation during procedure Leads to fluid overload and dilution effect Hyponatraemia Sx: confusion, nausea, agitation, visual changes Rx: Manage as hyponatraemia, replacing Na
61
Prostate cancer: epidemiology
Most common cancer in men. 26% of male cancer diagnosis. 1 in 8 men will get prostate cancer in their lifetime.
62
Prostate cancer: aetiology
Exact aetiology unknown. Growth of cancer is influenced by androgens. >95%: adenocarcinomas 75% from the peripheral zone. 20% transitional zone. 5% central zone. Often multifocal. Acinar adenocarcinoma (most common) from glandular cells that line prostate. Ductal adenocarcinoma from cells that line ducts: Grow and metastasise more rapidly
63
Prostate cancer: clinical
LUTS. Haematuria, dysuria, incontinence, haematospermia. Suprapubic/loin pain. Mets: bone pain, lethargy, anorexia. DRE: asymmetrical nodularity, firm
64
Prostate cancer: Investigations
PSA MRI prostate Targeted biopsy: transperineal, transrectal US guided Gleason Grading System: most common growth pattern + second most common
65
Prostate cancer: management
Low risk disease: active surveillance, radical treatments offered to those who show evidence of disease progression Intermediate/high risk: radical prostatectomy Metastatic: chemotherapy, anti-hormonal agents Radical prostatectomy: open approach, laparoscopic, robot. SE: ED, incontinence, bladder neck stenosis

X. MRCS: Anatomy (18 decks)

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