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Year 3 - Surgery > 5.02 Urology - The Kidney > Flashcards

5.02 Urology - The Kidney Flashcards

1
Q

What is pyelonephritis?

A

Inflammation of the kidney parenchyma and the renal pelvis, typically due to bacterial infection.

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2
Q

Explain the pathophysiology of pyelonephritis.

A

Acute pyelonephritis resulting from bacterial infection within the renal pelvis and parenchyma, which have ascended from the lower urinary tract or invaded from the blood stream or lymphatics.

Neutrophils infiltrate the parenchyma and cause inflammation.

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3
Q

What is the most common cause of pyelonephritis?

A

Bacterial - Escherichia coli

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4
Q

What are the risk factors for pyelonephritis?

A
  • obstructed urinary tract
  • neuropathic bladder injury
  • female gender (short urethra)
  • indwelling catheter
  • immunocompromised (e.g. diabetes mellitus, corticosteroid use)
  • renal calculi
  • sexual intercourse
  • menopause (ie. oestrogen depletion)
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5
Q

What are the clinical features of pyelonephritis?

A

Classic triad of:

  1. fever
  2. unilateral loin pain
  3. nausea and vomiting

Pts may also have symptoms of lower urinary tract infection.

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6
Q

What are the differentials for pyelonephritis?

A

Any patient presenting with back pain and tachycardia / hypotension should be assessed for potential ruptured AAA.

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7
Q

What are the investigations of pyelonephritis?

A
  • urinalysis (assess for nitrites and leucocytes)
  • urinary beta-hCG in women of child-bearing age
  • urine culture
  • routine bloods (e.g. FBC and CRP for inflammation; U&Es to assess renal function)
  • renal US for evidence of obstruction
  • CT KUB (non-contract CT imaging) to assess for obstruction
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8
Q

How is pyelonephritis managed?

A
  • empirical antibiotics
  • prescribe suitable analgesia
  • consider admission if unstable or immunocompromised
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9
Q

What are the complications of pyelonephritis?

A
  • severe sepsis
  • preterm labour in pregnant ladies
  • chronic pyelonephritis
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10
Q

What is emphysematous pyelonephritis?

A

A rare form of pyelonephritis caused by gas-forming bacteria, associated with a high-mortality rate.

Presents similarly to acute pyelonephritis but fails to respond to empirical antibiotics. CT imaging shows gas within the kidney.

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11
Q

Why is emphysematous pyelonephritis more common in diabetic patients?

A

Hyperglycaemic state promotes CO2 production from fermentation by enterobacteria.

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12
Q

What is the difference between simple and complex renal cysts?

A

Simple cysts have a well-defined outline and are thought to develop from the renal tubule epithelium.

Complex cysts have more complicated structures and have a risk of malignancy.

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13
Q

What are the risk factors for renal cysts?

A
  • increasing age
  • smoking
  • hypertension
  • male gender
  • gentics
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14
Q

Which specific genetic conditions increase the risk of renal cysts?

A
  • polycystic kidney disease
  • tuberous sclerosis
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15
Q

What inheritance pattern does polycystic kidney disease display?

A

Autosomal dominant polycystic kidney disease (ADPKD) most common.

Can be autosomal recessive but more rare.

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16
Q

ADPKD is caused by mutations of which genes specifically?

A

PKD1 and PKD2 genes

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17
Q

What are the clinical features of renal cysts?

A

Found incidentally on abdominal imaging - often asymptomatic.

May cause flank pain or haematuria.

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18
Q

What are the investigations for renal cysts?

A

Definitive diagnosis via CT or MRI imaging.

Ultrasound often picks up incidental findings but further imaging required.

19
Q

How are renal cysts managed?

A

Asymptomatic simple cysts do not need follow up treatment.

Symptomatic renal cysts can be managed with simple analgesia, but may require needle aspiration if there is significant impact.

Complex cysts must undergo continued surveillance or surgical intervention.

20
Q

What is the prognosis of renal cysts?

A

Most simple cysts are uncomplicated.

Risk of malignancy and other complications increases with complex cysts:
- infection
- rupture
- haemorrhage

21
Q

What are the two types of urinary tract stones that may develop:

a) in the kidney

b) in the ureter

A

a) renal stones

b) ureteric stones

22
Q

What is the most common structure of urinary tract stones?

A

Calcium oxalate stones most common

23
Q

What is the pathophysiology of urate stones?

A

High levels or purine within the blood (e.g. high red-meat diet, myeloproliferative disase) caused oversaturation of purine within the urine.

24
Q

What is the pathophysiology of cystine stones?

A

Homocystinuria caused oversaturation of cystine within the urine.

25
Q

For stones that enter the drainage the system of the urinary tract, name the three natural narrowed points where stones are most likely to impact.

A
  1. Pelviureteric junction (PUJ), where the renal pelvis becomes the ureter.
  2. Crossing the pelvic brim, where the iliac vessels travel across the ureter in the pelvis.
  3. Vesicoureteric junction (VUJ), where the ureter enters the bladder.
26
Q

What are the clinical features of renal stones?

A
  • pain (uteric colic)
  • sudden onset
  • loin to groin
  • nausea and vomiting
  • haematuria
  • tenderness in affected flank OE
27
Q

Give the reasoning behind the ureteric colic characteristic of renal stone pain.

A

Episodic pain occurring from increased peristalsis from around the site of obstruction.

28
Q

What are the differential diagnoses for renal stones?

A
  • pyelonephritis
  • ruptured AAA
  • biliary pathology
  • bowel obstruction
  • lower lobe pneumonia
29
Q

What investigation are used to diagnose renal stones?

A

CT KUB is gold standard to identify stone disease.

Can use ultrasound to assess for hydronephrosis.

Routine bloods (ie. FBC, CRP, U&Es, urate and calcium levels) used to assess inflammation and renal function.

30
Q

How are renal stones initially managed?

A
  • fluid resuscitation
  • most renal stones pass spontaneously (<5mm)
  • sufficient analgesia (ie. opiates)

If there is evidence of infection, IV antibiotic therapy and referral to urology indicated.

31
Q

Give the 4 indications alongside renal stones that would warrant hospital admission.

A
  1. post-obstructive AKI
  2. uncontrollable pain despite analgesia
  3. Evidence of infected stones
  4. Large stones (>5mm)
32
Q

How can renal stones be definitively managed?

A
  • shock waves to break up the stones
  • percutaneous access to kidney to remove stone
  • retrograde access to kidney via ureter to remove stone
33
Q

What are the complications of renal stones?

A
  • infection
  • AKI
  • renal scarring
  • loss of kidney function (CKD)
34
Q

What is the main risk factor for bladder stones?

A

Urine stasis within the bladder, for example chronic urinary retention.

35
Q

Clinical features of bladder stones.

A
  • LUTS

If bladder stones persist, they will chronically irritate the epithelium and predispose to the development of SCC bladder cancer.

36
Q

What is the most common form of renal tumour?

A

Renal cell carcinoma

37
Q

Describe the pathophysiology of RCC.

A

Adenocarcinoma of the renal cortex, appearing in the upper pole of the kidney.

RCCs can spread via direct invasion to perinephric tissues, adrenal glands, renal veins or the inferior vena cava.

Can also spread haematogenously to the bones, liver, brain and lung.

Can also spread lymphatically to pre-aortic and hilar nodes.

38
Q

What are the risk factors for RCC?

A
  • smoking
  • industrial exposure to carcinogens (e.g. lead)
  • dialysis
  • hypertension
  • obesity
  • anatomical abnormalities (ADPKD)
39
Q

What are the clinical features of RCC?

A
  • haematuria (visible or non-visible)
  • flank pain
  • flank mass
  • lethargy
  • weight loss
40
Q

What investigations are warranted if RCC is suspected?

A
  • routine blood tests
  • urinalysis
  • ultrasound
  • CT (GOLD STANDARD!!!)
  • biopsy of renal lesions
41
Q

How is localised RCC managed?

A
  • laparoscopic surgical removal of the tumour
42
Q

How is metastatic RCC managed?

A
  • immunotherapy
  • metastasectomy
  • nephrectomy

NB: Chemotherapy generally ineffective.

43
Q

What is the prognosis of RCC?

A

At presentation, approximately 25% of cases have metastases.

5 year survival is approx. 60%.

Year 3 - Surgery (30 decks)

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