9 - KUB Flashcards

Question

What are some complications of recurrent kidney stones and how can we prevent stones from recurring? [3]

Answer 1

- Infection - AKI - Renal scarring and loss of kidney function with repeated stones

Answer 2

- Urinary stasis from **chronic urinary retention** or secondary to **schistosomiasis** or as **passed ureteric stones** - Present with LUTS - Treated by **cystoscopy** allowing them to drain or lithotripsy - Chronic irritation if left can cause **SCC of the bladder**

Answer 3

1. VUJ vesico uteric junction 2. Pelvic brim 3. PUJ pelvic uretic junction

Answer 4

- Composition? - Why have they got this stone now? - Any predisposing factors? - Any anatomical abnormalities? - Any family history? - Any infection above the stone?

Answer 5

**Inflammation** of the **kidney parenchyma** and the **renal pelvis.** Uncomplicated if non-immunocompromised and normal anatomy, complicated otherwise From **bacteria** either **ascending the lower urinary tract,** from the **blood stream** (infective endocarditis or septicaemia) or rarely from **lymphatics** from retroperitoneal abscess **Neutrophils infiltrate tubules** and interstitium and cause **supparative inflammation** (streaks of **pus** and renal cortical abscesses)

Answer 6

**Most common:** E.Coli **Others:** Klebsiella, Proteus, Enterococcus faecalis (catheters), Staphylococcus aureus (catheters), Staphylococcus saprophyticus (commensal), and Pseudomonas (catheters) **Immunocompromised:** mycobacterium, yeast, fungi

Answer 7

**- Factors reducing antegrade flow of urine:** e.g BPH, spinal cord injury **- Factors promoting retrograde ascent of bacteria:** female short urethra, indwelling catheters and JJ stents, VUR **- Factors predisposing to infection or immunocompromise:** DM, untreated HIV, corticosteroids **- Factors causing colonisation:** renal calculi, menopause (less oestrogen), sexual intercourse Vesicoureteral reflux (VUR) is a condition in which urine flows backward from the bladder

Answer 8

**- Triad:** fever, N+V, unliateral loin to groin pain developing over 24-48h **- LUTS:** frequency, dysuria, urgency, haematuria - Costovertebral angle tenderness with/without suprapubic tenderness (consider AAA back pain) **- DD:** ruptured AAA, renal calculi, acute cholecystitis, ectopic pregnancy, PID, diverticulitis, lower lobe pneumonia

Answer 9

- **Urinalysis** (nitrates, leucocytes, b-HCG) Human chorionic gonadotrophin - **Urine culture** before starting abx - **Renal US** to see if obstruction as obstruction+infection is surgical emergency - **Non-contrast CT KUB** if obstruction suspected

Answer 10

- A to E **- Trimethoprim or Co-amoxiclav** IV abx **- IV fluids,** analgesia, antiemetics **- Admit if clinically unstable**, significant dehydration, or with co-morbidities such as diabetes mellitus, renal transplant graft, immunocompromised - Consider either **US or CT KUB** and **flexible cystoscopy** for males with no risk factors/not responding to abx to check for **pyonephrosis** and **perinephric abscess** that need draining

Answer 11

- Severe sepsis - Renal scarring leading to CKD - Premature labour - Pyonephrosis - Chronic Pyelonephritis - Emphysematous Pyelonephritis

Answer 12

**_Chronic:_** ## Footnote **- Fibrosis** and destruction of the kidney due to repeated events of pyelonephritis - More common in obstructed systems resulting in **urinary reflux**, such as strictures caused by UTIs, VUR **- Small, scarred shrunken kidney** - More common in children, asymptomatic, **reverse any underlying cause** and consider **prophylactic abx** **_Emphysematous:_** - Caused by gas forming bacteria and has high mortality - **Presents like pyelonephritis but doesn't respond to abx** - **CT imaging** will show **gas** within and around kidney - Most common in diabetics as high glucose converted to CO2 by enterobacteria - If mild **broad-spectrum anti-microbial cover** - If severe **nephrostomy insertion** or **percutaneous drainage** and possible nephrectomy

Answer 13

- Mostly in developed countries between 50-70 years - **Adenocarcinoma** of the renal cortex usually in **PCT** and in the **upper pole of the kidney** - Can spread by **direct invasion** of perinephric tissues, adrenal gland, renal vein (tumour thrombosis) IVC; via **lymphatics** to pre-aortic and hilar nodes; or **blood** to the bones, liver, brain and lung.

Answer 14

- Transition cell carcinoma (urothelial) - Nephroblastic carcinoma (Wilm's) - SCC of the bladder (schistosomiasis chronic inflammation)

Answer 15

- **Most common:** smoking - Industrial exposure to carcinogens (cadmium, lead, aromatic hydrocarbons) - Dialysis - HTN - Obesity - Anatomical abnormalities (horseshoe, PCKD) - Genetic disorders (BAP1, Birt-Hogg-Dube syndrome)

Answer 16

**_Triad:_** - **Haematuria** (V or NV) **- Flank pain** **- Flank mass** - Vague symptoms like weight loss - Left sided by have **left varicocele** as tumour compresses testicular vein - **Polycythaemia** from EPO secretion - HTN

Answer 17

**- Routine bloods** (FBC, U+E's, Ca, LFTs, CRP) - **Urinalysis** or **non-visible haematuria** and **cytology** - Initially **US KUB** **_- Gold standard:_** abdomen-pelvis pre and post IV contrast CT with additional chest CT for staging **- Biopsy**

Answer 18

**_Localised_** ## Footnote - If small **partial nephrectomy** - If large **radical nephrectomy** to remove kidney (not adrenal gland), perinephric fat, local lymph nodes - If not suitable for surgery **percutaneous radiofrequency ablation** or p**ercutaneous cryotherapy** with renal artery embolisation before - If small slow growing and little life expectancy left anyway then can just **monitor** **_Metastatic_** - **Nephrectomy combined with immunotherapy (IF-a/IL2)** as chemo not suitable - **Biological agents** like*** Sunitinib/Pazopanib (Tyrosine Kinase inhibitors)*** - **Metastasectomy** (surgical resection of solitary metastases) * ***This reduces tumor blood supply, slows tumor growth, and prevents metastasis.***

Answer 19

- 25% have metastasis at presentation - 60% 5 year survival if have nephrectomy

Answer 20

Fluid filled sacs: **_Simple:_** Well defined outline and homogenous features. Made from renal tubule epithelium in response to previous ischaemia **_Complex:_** thick walls, septations, calcification, or heterogeneous enhancement on imaging. Classified with Bosniak classification and have risk of malignancy

Answer 21

- Increasing age - Smoking - HTN - Male - Genetic conditions (ADPKD, tuberous sclerosis, and Von Hippel-Lindau disease) CONSIDER RCC AS A DIFFERENTIAL

Answer 22

- **CT or MRI imaging,** with **pre- and post-enhancement** scans with **IV contrast.** Use **Bosniak scoring system t**o stage after CT **- US** picks it up incidentally - **Check U+E's** for renal function and monitor this regularly if have genetic disease that predisposes to cysts

Answer 23

**- Asymptomatic:** no follow up or treatment **- Symptomatic simple:** simple analgesia or needle aspiration with laparoscopic cyst deroofing to prevent recurrence **- Complex:** Depends on Bosniak stage ranging from surveillance to nephrectomy **- Complications:** infection, haemorrhage, rupture, progression to malignancy

Answer 24

**_Stress_** ## Footnote - **Intra-abdominal pressure higher than urethral pressure** such as coughing, straining, laughing sneezing. - Weakness of pelvic floor seen post-partum, obesity, menopause, constipation, pelvic surgery (TURP) **_Urge_** - OAB (detrusor hyperactivity) leading to increased intra-vesicular pressure - Neurogenic, infection, malignancy and cholinesterase inhibitors can all cause **_Mixed_** - Combination of two **_Overflow_** - Chronic urinary retention as stretch of bladder wall damages efferent fibres of sacral reflex and loss of bladder sensation - BPH, spinal cord injury **_Continuous_** - Anatomical abnormality (such as ectopic ureter) or bladder fistulae (e.g. vesicovaginal fistula) or due to overflow

Answer 25

**- MSU dipstick** to check for infection and haematuria **- Post-void bladder scan** **- Urodynamic assessment** for UI if conservative management doesnt work **- Outflow urodynamics** - Others: cystoscopy, intravenous urogram, vaginal speculum examination, or MRI imaging

Answer 26

**_Storage:_** Under sympathetic control by T10-L2 left and right hypogastric and S2-S4 somatic pudendal nerve under control of L centre in the pons **_Voiding:_** Under parasympathetic control S2-S4 pelvic splanchnic

Answer 27

**_Conservative_** ***- Lifestyle advice:*** less caffeine and alcohol, weight loss, smoking cessation, drinking less at end of day ***- Pelvic floor muscle training*** for at least 3/12 - If PFMT doesn't work offer ***duloxetine (serotonin-norepinephrine uptake inhibitor)*** **_Surgical_** ***- Tension-free vaginal tape*** - Open colposuspension (involving elevation of the bladder neck and urethra through a lower abdominal incision) - Intramural bulking agents - Artificial urinary sphincter

Answer 28

**_Conservative_** - Lifestyle advice (same as UI) ***- Bladder training*** for minimum of 6/52 ***- Antimuscarinics*** like oxybutynin/tolterodine **_Surgical_** ***- Botulinum toxin A injections*** - Percutaneous sacral nerve stimulation - Augmentation cystoplasty - Urinary diversion via ileal conduit.

Answer 29

- Bladder cancer is most common urinary tract cancer. Most common in men and caught early so good prognosis **- TCC (90% of cases)**, SCC, Adenocarcinoma, Sarcoma

Answer 30

**- Most important:** smoking and increasing age - Aromatic hydrocarbons (industrial dyes and rubber) - Schistosomiasis (SCC) - Previous radiation to pelvis

Answer 31

**- Painless haematuria** (either V or NV) **- Recurrent UTIs** or **LUTs** - Clinical exam usually remarkable - If metastatic may have systemic symptoms like weight loss and lethargy

Answer 32

**- Urgent flexible cystoscopy** under local anaesthetic - **Rigid cystoscopy** under general if suspicious lesion found on flexible - **Biopsy** on cystoscopy and consider **TURBT** **- CT staging** to look for muscle invasive and plan TURBT **- Urine cytology** (if cancer in cytology but not on cystoscopy then random biopsy on cystoscopy)

Answer 33

**- Carcinoma in situ or T1:** TURBT **- Higher risk in situ:** adjuvant intravesical therapy, such as Bacille Calmette-Guerin (BCG slowing progression) or Mitomycin C as an outpatient. Stimulates type IV hypersensitvity to activate immune cells to tumour antigens **- High risk or limited response to above:** radical cystectomy **- Regular surveillance** by cytology/cystoscopy of all people as high recurrence rate and if recurs more invasive

Answer 34

AFTER TURBT, Adjuvant intravesical theraphy BCG or Mitomycin C, stimulates type IV hypersensitivity.

Answer 35

**- Radical cystectomy with neoadjuvant chemotherapy** with cisplatin combination **- Ileal conduit formation with urostomy** or **bladder resconstruction** from small bowel draining either urethral or catheter **- Regular follow-up with CT** to monitor for local and distant recurrence. Also check **B12 and folate** annually due to resection ileum

Answer 36

**- Chemotherapy:** either **cisplatin‑based regimen or a carboplatin plus gemcitabine-based regime** - Any symptoms of the disease, such as pelvic pain, ongoing bleeding, or urinary frequency should be discussed at MDT **- Palliative options** should be discussed

Answer 37

- Patients who have had bladder cancer are at higher risk of developing upper urinary tract and urethral cancers - If superficial 5 year survival of 90%, if metastatic invasive 10-15%

Answer 38

Peritonitis patient will lay still but renal calculi patient will be rolling around in pain as calculi not irritating the peritoneum Pyelonephritis has LUTs but renal calculi will not unless calculi has reached VUJ

Answer 39

1. Flank pain 2. Flank mass 3. Haematuria Not often that all three at once

Answer 40

- Urine dipstick - Routine bloods inc U+Es and psa - DRE - Bladder scan and catheterise if retention - CT urogram

Answer 41

Prostate cancer with bone involvement!!!

Answer 42

To remove a blood clot in the bladder causing obstruction, one for balloon, one for irrigation, one for bag

Answer 43

**Calcium Oxalate** - Fluids - Analgesia - Alpha blockers (Tamsulosin)

Answer 44

* Good hydration * Thiazides * Low protein and low salt diet

Answer 45

* Haematuria * Chronic high pressure retention

Answer 46

* Overflow incontinence overnight * Can lead to hypoK and cardiac arrhythmias so need admitting ASAP with catheter and monitoring for **post-obstructive diuresis (hourly urine output, weight BD, U+Es BD)** Bis in Die Twice daily

Answer 47

* Overflow incontinence overnight * Can lead to hypoK and cardiac arrhythmias so need admitting ASAP with catheter and monitoring for post-obstructive diuresis (hourly urine output, weight BD, U+Es BD)

Answer 48

**Initial:** Urethral origin **Mixed:** Kidney origin **Terminal:** Bladder origin

Answer 49

* Three way catheter and irrigate * Even if due to anticlotting drugs need to investigate in haematuria one stop clinic

Answer 50

Need to check whole urinary tract **Visible:** CT urogram, Flexi cystoscopy, PSA, PR exam **Non-Visible:** US KUB, same as above

Answer 51

**Non-contrast CT KUB** Check for haematuria on urinalysis, if none then unlikely

Answer 52

* Lower abdominal pain * Testicular pain (VUJ) * Labia pain (VUJ)

Answer 53

Check their U+Es, urinalysis and US for hydronephrosis!!!!!!!!