UROGENITAL SYSTEM

1. UROGENITAL SYSTEM Kidney & Ureter PREPARED BY DR. PANCHAJANI.R

2. Kidney ANATOMY • Situated retroperitonially in the posterior abdominal wall one on each side of vertebral column. • Extends from upper border of T12 to the centre of the body of L3 vertebra. • 11 cm long ,6cm broad,3cm thick, lateral border convex, medial border concave with a hylum. • Structures in hylum – renal artery ,renal vein, renal pelvis. • upper pole –suprarenal gland, • lower pole- 1inch above iliac crest • Capacity of renal pelvis- 10ml

3. Kidney • Renal angle- angle between the 12thrib & outer border of sacrospinalis. Pressure over this point elicits pain in kidney lesions. • Hepato renal pouch- related to upper pole of kidney. collection of extravasated fluid in this pouch following liver& biliary tract surgeries. • Outer brownish cortex , inner pale medulla • Pelvis divides 2-3 major calyces which then divides in to 7-13 minor calyces. • Each kidney – 1-3 million Uriniferous tubules, each has a Collecting part(Collecting tubule) & Secretory part( Nephrones )

4. Kidney • Blood supply- Renal artery arises from abdominal aorta.(between L1-L2) • 95% of abdominal aneurism arises below the level of origin of Renal artery. • Nerve supply- T10, 11,12 • Lymphatic drainage- Para-aortic nodes.

5. URETER • 25- 30 cm long,3-4mm in diameter. • Begins with in the renal sinus as a funnel -shaped dilatation called renal pelvis. It open at the lateral wall of the trigone of the urinary bladder. Not attached to any fixed structures. so easily displaced or obstructed • In females uterine artery crosses the ureter about 2cm lateral to the cervix. (important in hysterectomy) • Normal sites of constrictions - PUJ, At the brim of lesser pelvis, Along its passage through the bladder wall. • Arterial supply – upper- branches of renal & adrenal arteries, middle- branches of arteries of posterior abdominal wall. Lower(pelvic part) - branches of internal iliac arteries • The mean size of ureters on obstructed side was 7mm, stones less than or about 5mm in size can pass through the urinary tract on their own.

6. INVESTIGATIONS • Blood – RFT- urea, creatinine, BUN, • Urine - microscopic, macroscopic, cytological, bacteriological,biochemical • Plain X-ray-- KUB • Taken in supine position which cover pubic symphysis & lower 2 ribs • Bony parts looked any abnormality • Kidney shadow- visualized in plain x-ray KUB due to difference in the density between kidney (high vascularity) & perinephric fat(low vascularity). • Findings noted are size, location, calcification & stones. • Perinephricfat is absent in children so kidney shadows are not visualized. • Psoas shadow visualised in normal KUB. Obliterated in enlarged kidney, TB spine, psoasabscess, scoliosis, Ca, splenic injury. • Uretericline– looked for any radio opaque shadow( ureteric stone ) • Any lesion in bladder, prostate, urethral areas.

7. Investigations 4. Intra venous urogram (IVU/IVP) • Renal fuction must be normal • Hydronephrosis - clubbing of calyces • Hoarse shoe kidney - flower vase appearance • Ureterocele - cobra head appearance • Poly cystic kidney - spider leg appearance • RCC - irregular filling defect, spider leg • To see functions of kidney in stones , obstructions.

8. Investigations 3. Retrograde pylography(RGP) Urinary TB, Urothelialtumours 4. Renal angiogram Indications • Renal artery stenosis, RA atheroma, RA aneurysm ,RCC • Arterial anomalies 5. Micturatingcystourethrography (MCU) Indications • Vescicoureteric reflux • Posterior urethral valves 6. Ascending urethrogram • Stricture urethra • USG- High resolution for size, thickness, obstructions • Trans rectal USG- for Ca prostate •  CT, MRI, Isotope Renography, Cystoscopy

12. HAEMATURIA Gross – visible Microscopic-More than 5RBC ‘S/ HPF • Early(initial) H – urethral origin distal to external sphincter • Terminal H - Bladder neck or prostate origin • Diffuse(total) – in the bladder or upper urinary tract • False H - Discolouration of urine from pigments such as food colouring and myoglobin • Silent H - Tumour of kidney or bladder

13. Haematuria – causes • Renal injury • Urinary stones • Wilm’stumour • TB • RCC • Cystitis • Bladder tumour • Urinary bilharziasis • BPH, Ca prostrate • Renal infart • Glomerulonephritis • Blood dyscrasias

14. Haematuria – investigations • Urine R/E, C&S • USG- Stones, tumours • Cystourethroscopy- for bladder& urethral pathology • IVU- for functions of kidney • Urinary cytology- for malignancy • BT, CT, PT, Platelet count • CT abdomen • RFT Management- cause should be identified & treated

15. Hoarse shoe kidney • fusion of lower pole common • common site -in front of the 4th lumbar vertibrae • Mass in the mid line of 4th lumbar vertebrae • IVU – medialisation of lower calyces & curving of ureter like a flower vase

16. Poly cystic kidney • Bilateral • Occurs at the junction of distal tubule and the collecting duct • Renal mass moves with respiration, ballotable, movable • 75% - hypertension, 25% haematuria • IVU- Spider leg pattern with an elongated compressed renal pelvis,narrowed & stretched calyces.

17. Retrocavalureter • Developmental defect of IVC, right ureter passes behind the IVC, right hydronephrosis with hydroureter. • IVU- Hydronephrosis with reverse J sign • Treatment( Tt) - Anderson Hynes operation

18. URETEROCELE • Cystic enlargement of the intra mural portion of ureter due to congenital atresia of the ureteric orifice. • IVU- Adder head or cobra head appearance. • Cystoscopy– transluscent thin walled cyst surrounding the ureteric orifice • Tt. - Cystoscopicuretericmeatotomy.

19. Renal injuries • Associated with Blunt injury abdomen • It is extraperitoneal Types- • small & large subcapsular • Cortical laceration • Laceration with haematoma • Medullarylaceration with bleeding in to pelvis • Cortico- medullary complete laceration • Hilarinjury – most dangerous

20. Renal injuries Clinical features • Features of Shock • Haematuria, sometimes delayed profuse haemorrhage ( haematuria between 3rd day & 3rd week), clot colic • Swelling & tenderness in loin. • Paralytic ileus with abdominal distension

21. Renal injuries Investigations • CT Scan - Grading of injury, Associated injuries, functions of kidney. • USG Abdomen - site& type of injury., haemoperitoneum, associated injuries, effect of therapy by repeating it. • IVU - Functions of injured& normal Kidney , • RFT - Blood Urea, Creatinine, electrolytes, haematocrit, blood Grouping. • Other - Chest X-ray, CT, plain X-ray abdomen .

22. Renal injuries Treatment • Conservative - catheterization, blood transfusion, monitor vital signs, urea, creatinine etc.. • Surgical- indications- blood loss, haematoma, hilar injury • 10- 20 % cases -Gentle suturing, Nephrostomy, Nephrectomy

23. RENAL TUBERCULOSIS • Secondary to pulmonary TB, Bacilli causes lesions in the renal cortex & it spreads along the ureter causing tubercular ureteritis & stricture ureter. Pathology • Through blood it reaches the glomeruli causing caseatinggranuloma with Langerhan’stype of giant cells & epitheloid cells. These granuloma united to form, • TB papillary ulcer • Cavernous form • Hydronephrosis • Pyonephrosis • perinephric abscess, calcification, casceous kidney, miliary TB, TB cystitis leads to golf hole ureter & thimble bladder,prostatitis, vesciculitis, stricture etc..

24. RENAL TUBERCULOSIS Clinical features • Common in males, right side, frequency, polyuria, sterile pyuria painful micturition with often haematuria , renal pain, suprapubic pain. • Kidney rarely palpable. Enlarged prostate & seminal vescicles. Acute pyelonephritis. Features of urinary stones, UTI, Dyspareunia , menstrual irregularities. Fever& weight loss, cough, expectoration, haemoptysis.

25. RENAL TUBERCULOSIS Investigations • Hb% & ESR increased • Mantoux test positive. • Chest X- ray • Three consecutive early morning urine is sent for microscopy & culture • USG • Plain X- ray KUB - shows calcification • CT abdomen& pelvis – see hydronephrosis, shrunken kidney, stricture, necrosis • IVU – Hydrocalyx, narrowing of calyx, stricture ureter • RGP- is useful, ureter, pelvis, calyces seen, sampling of urine taken • CYSTOSCOPY- multiple tubercles, bladder spasm, oedema of uretericorifice forming golf hole ureter • MCU- to see ureteric stricture , reflux

26. RENAL TUBERCULOSIS Treatment • Anti TB treatment • Hydronephrosis - anderson’spyeloplasty • TB abscess- drainage • Ureteral stricture – Stenting/ Reimplantation of the ureter in to bladder • Thimble bladder - hydraulic dilatation/ ileocystoplasty/ caecocystoplasty/ sigmoid colocystoplasty • In unilateral lesion with gross impairement of renal function- nephroureterectomy

27. Hydronephrosis • It is an aseptic dilatation of whole or a part of pelvi-calyceal system of kidney due to partial or intermittent obstruction to the out flow of urine. • Hydronephrosis refers to dilatation of renal pelvis and calyces with accompanying atrophy of the parenchyma. • Cause by obstruction to the outflow of urine

28. Hydronephrosis – obstruction levels • Renal pelvis • Pelviureteric junction • Ureter • Bladder • Urethra

29. Hydronephrosis – causes • Aetiology ; it can be unilateral/ bilateral Unilateral • Extramural- • Aberrant renal vessels( vein/ artery)compressing the ureter - common on left side • Compression by a growth/ Tumour- Ca cervix, Ca rectum, prostrate, colon etc.. • Retroperitoneal fibrosis • Retrocavalureter

30. Hydronephrosis – unilateral causes Intramural • Congenital PUJ obstruction • Ureterocele • Inflammatory stricture • Ca ureter • Narrow ureteric orifice • Stricture ureter (following removal of stones, pelvic surgeries, TB ureter) Intra luminal • Stone in the renal pelvis or ureter • Sloughed papilla in papillary necrosis

31. Hydronephrosis – Bilateral causes Bilateral • Congenital- stricture of external urethral meatus, pinhole meatus Congenital posterior urethral valve, urethral atresia. • Acquired - BPH Ca prostate Post operative bladder neck scarring Inflammatory / traumatic urethral stricture Phimosis Ca cervix involving both ureters Bladder Ca • Congenital PUJ obstruction is the most common cause of HN • Often it is bilateral & presentation on one side is earlier than the other side. • Aberrant renal artery or vein in the lower pole can compress PUJ causing HN. Renal angiogram confirms the diagnosis.

32. Pathophysiology • Due to aetiological factors  obstruction of the urine flow fluid backs up in to the kidney causing dilatation of renal pelviscausingbarotrauma/ pressure trauma  higher pressure causes irreversible destruction of the nephrones hypertrophy of the kidney as a consequence of increased work load hydronephrosis  renal failure

33. Pathology • Changes depends on whether the kidney has an extrarenal or intra renal pelvis- commonly extra renal • In extra renal pelvis first the pelvis alone become dilated , at time goes on if the obstruction is not relieved calyces become dilated& renal parenchyma is progressively destroyed by pressure atrophy • In a kidney with intra renal pelvis destruction of parenchyma occurs rapidly

34. Pathology • Kidney is massively enlarged with greatly distended pelvicalyceal system. • The renal parenchyma is compressed and atrophied with obliteration of the papilla and flattening of the pyramids. • Pressure changes on the pelvis later calyces & renal parenchyma. • Gradually parenchyma thins out due to destruction & it dilates& affects secretory function • Parenchymal thickness of less than 2 mm is unlikely to function .In bilateral cases such patients will go for renal failure. • Depending on obstruction one or both ureter may also dilated( hydroureter)

35. HYDRONEPHROSIS

37. Symptoms & signs of HN • Male: female- 2: 1 • Right side is more common • Asymptomatic in some conditions • Dull aching loin pain with dragging sensation or heaviness (Pain is felt in the renal area.) worse by excessive fluid intake • Haematuria • Anuria/ oliguria • Urinary infection, dysuria, frequency • Calculi • Azotemia – abnormaly high level of nitrogen containing compounds( urea, creatinine etc..) in blood • Unexplained vague GIT symptoms • Some large hydronephrosis can be palpable( mass in the loin which is mobile, ballotable, moves with respiration with dullness in renal angle). • Dietl’s crisis- after an acute attack of renal colic , swelling in the loin is seen which disappears after passing large volume of urine. • Occassionally hypertension. • Distension of bladder if urethra is obstructed.

38. Clinical course • Bilateral complete obstruction produce anuria which need soon medical attention. • Incomplete bilateral obstruction produce polyuria rather than oliguria as a result of defect in tubular concentrating mechanism

39. Clinical course • Unilateral hydronephrosis may be silent for long period unless other kidney is affected • Bilateral hydronephrosis usually lead to uremia • Early removal of obstruction can return the kidney function • However with the time the changes become irreversible

40. INVESTIGATIONS - HN • RFT- urea, creatinine • Urine microscopy • USG • IVU • CT • Isotope renography- DTPA scan-pentetic acid • Complications- pyonephrosis, perinephric abscess, renal failure in bilateral cases

41. Treatment -secondary to cause • Stones- pyelolithotomy/ ureterolithotomy • Stricture – stricturoplasty or excision and end to end anastamosis • Aberrant vessel- transection of the ureter and anastomosis in front of the vessel. • BPH- TURP • Ca prostrate- TURP+ Hormonal therapy • Urethral stricture- urethroplasty • Meatal stenosis- meatoplasty • Phimosis – circumcision

42. Management of congenital hydronephrosis • Patients with congenital PUJ dysfunction presents congenital hydronephrosis • Congenital hydronephrosis can be defined as more than 10mm antero-posterior diameter of renal pelvis at 20 weeks of gestation. • Management differs according to the grades of hydronephrosis, which is based on renal pelvic diameter.

43. MANAGEMENT • Grading- mild -11-20mm • Moderate-21- 35mm • Severe- > 35mm • Mild case is managed conservatively with serial monitoring of pelvic diameter by USG and of renal function. • Moderate is also managed by serial monitoring. Any deterioration of renal function is an indication for surgical intervension • Severe HN should be treated early Anderson – Hynes pyeloplasty to prevent permanent damage to kidney.

44. Anderson Hynes Pyeloplasty • In this operation , the upper third of the ureter and the renal pelvis are mobilised. • Anastomosis is made between ureteric end and kidney. • A nephrostomy tube is passed , which serves to protect the anastomosis

45. Anderson Hynes Pyeloplasty

46. Pyonephrosis • Collection of pus in the pelvicalyceal system (a multi loculated cyst). Causes – • Infection of hydronephrosis • Following acute pyelonephritis • Complication of renal calculi( stone in renal pelvis or stag horn calculi) Clinical features- usually unilateral • Triad – anemia, fever, loin swelling • Tender mass in loin, smooth, soft, not mobile , not move with resp. • Cystitis, pyuria, burning micturition. • Fever, chill, rigor

47. Pyonephrosis Investigations • Plain X-ray KUB – For Renal calculi • IVU- For HN • Cystoscopy – cystitis • USG • DTPA Scan Treatment – medicinal treatment • Drainage- through loin incision & nephrostomy tube • Kidney is totally destructed- sub capsular nephrectomy • In Bilateral- bilateral nephrostomy with J stending to keep ureter patent

48. RENAL CARBUNCLE • A localised inflammatory necrotic mass of tissue involving renal parenchyma. • Causative organism- staphylococcus aureus & coliforms. • Source- cutaneous infection like boil & carbuncle. • Presents as ill-defined tender swelling in the loin, with pyrexia, leucocytosis. • Staphylococci can be isolated from the urine. • IVU- obliteration of group of calyces like RCC • Treatment- Drainage with malecots catheter • Severe cases- Nephrectomy

49. PERINEPHRIC ABSCESS Causes • Infection of a perinephrichaematoma • Perforation of renal abscess or carbuncle • TB perinephric abscess • Extension of cortical abscess • Haematogenous spread • Extension of appendicular abscess • Periureteral lymphatic spread C/F- high fever, fullness in the loin, tenderness and rigidity, scoliosis with concavity towards the side of abscess.

50. PERINEPHRIC ABSCESS Investigations- TC elevated • X- ray KUB- obliteration of psoas shadow, scoliosis, elevation of hemi diaphragm. • IVU- 2 films- lying down & erect position. Normally in erect posture downward displacement of kidney is seen. It is not seen in perinephric abscess- Mathe’s sign. • USG • CT Scan is diagnostic Treatment- medicinal • Under G/A drainage through lumbar incision , pus sent for C/S