Fundamentals of Upper Urinary Tract Drainage

Question 1

The renal parenchyma is composed of the cortex and the medulla. The cortex, outermost, contains the __ and ___. The more interior medulla contains the ___. These are inverted cones (the base of which is superficial and the apex is deep) that comprise the loops of Henle and the collecting ducts, which coalesce at the apex of the pyramid into papillary ducts that open on the surface of the renal papillae. There are approximately___ draining into each papilla. The columns of Bertin are ____ that surround the renal pyramids except at their ____

Answer 1

The renal parenchyma is composed of the cortex and the medulla. The cortex, outermost, contains the glomeruli and proximal and distal convoluted tubules. The more interior medulla contains the renal pyramids. These are inverted cones (the base of which is superficial and the apex is deep) that comprise the loops of Henle and the collecting ducts, which coalesce at the apex of the pyramid into papillary ducts that open on the surface of the renal papillae. There are approximately 20 papillary ducts draining into each papilla. The columns of Bertin are invaginations of cortical tissue that surround the renal pyramids except at their apices.

Question 2

bords of lumbar notch

Answer 2

It is bounded superiorly by the latissimus dorsi muscle and the 12th rib, medially by the sacrospinalis and quadratus lumborum muscles, laterally by the transversus abdominis and external oblique muscles, and inferiorly by the internal oblique muscle

Question 3

The American Urological Association (AUA) does not recommend/recommends periprocedural antimicrobial prophylaxis for all cases of percutaneous renal surger

Answer 3

The American Urological Association (AUA) recommends periprocedural antimicrobial prophylaxis for all cases of percutaneous renal surger

Question 4

except at the upper poles where the diaphragm is posterior the pleura can be violated during percutaneous entry into the upper pole of the kidney. This risk is greater with more cephalad access. The lung is above the ___, so direct lung injury is unlikely unless the ____is used as the entry site.

Answer 4

except at the upper poles where the diaphragm is posterior (Fig. 12.2). The pleura can be violated during percutaneous entry into the upper pole of the kidney. This risk is greater with more cephalad access. The lung is above the 11th rib, so direct lung injury is unlikely unless the 10th intercostal space (superior to the 11th rib) is used as the entry site.

Question 5

the ascending and descending colon can be lateral or even posterior to the right and left kidneys, respectively. The apposition of the colon to the kidney varies with location; it is greatest on the ___and at the ___

Answer 5

the ascending and descending colon can be lateral or even posterior to the right and left kidneys, respectively. The apposition of the colon to the kidney varies with location; it is greatest on the left side and at the lower pole

Question 6

most calyces of the____ are suitable for percutaneous access from the posterior approach, whereas care must be taken to select a ___ in the middle and lower groups

Answer 6

most calyces of the upper pole are suitable for percutaneous access from the posterior approach, whereas care must be taken to select a posterior minor calyx in the middle and lower groups

Question 7

The potential for arterial injury is least in Brödel’s line, an ____ approximately at the____ of the kidney, extending from the____ of the kidney (limited by the circulation of the apical anterior segmental artery) to the ___ of the kidney (limited by the circulation of the lower anterior segmental artery)

Answer 7

The potential for arterial injury is least in Brödel’s line, an avascular plane approximately at the lateral margin of the kidney, extending from the superior apex of the kidney (limited by the circulation of the apical anterior segmental artery) to the lower pole of the kidney (limited by the circulation of the lower anterior segmental artery)

Question 8

T/F

evidence suggests that when the antimicrobial is being administered only for prophylaxis (i.e., not treatment of known or presumed infection), immediate perioperative treatment for percutaneous nephrolithotomy (24 hours or less) is just as effective as a longer course and is therefore preferred

Answer 8

true

Question 9

before undertaking percutaneous renal access. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, and anticoagulants, with few exceptions, should be discontinued before planned surgery as follows: aspirin, ___ week; warfarin, ____ week; clopidogrel, ___ days; and NSAIDs, ___

Answer 9

efore undertaking percutaneous renal access. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, and anticoagulants, with few exceptions, should be discontinued before planned surgery as follows: aspirin, 1 week; warfarin, 1 week; clopidogrel, 5 days; and NSAIDs, 3 to 5 days

Question 10

Access above the___ is associated with a high incidence of pleural violation and lung injury and should be avoided unless absolutely necessary.

Answer 10

10th

Question 11

The lumbar notch, also known as the __ or __ lumbar triangle, has been reported to be a reliable landmark for blind percutaneous renal access

Answer 11

The lumbar notch, also known as the superior lumbar triangle or Grynfeltt lumbar triangle, has been reported to be a reliable landmark for blind percutaneous renal access

Question 12

If there is noticeable bleeding from the tract after sheath removal following an otherwise unremarkable procedure, this suggests bleeding from ___. Hemostatic maneuvers such as___ or placement of hemostatic material can be considered, but in general the best management is ____

Answer 12

If there is noticeable bleeding from the tract after sheath removal following an otherwise unremarkable procedure, this suggests bleeding from intraparenchymal vessels. Hemostatic maneuvers such as cauterization or placement of hemostatic material can be considered, but in general the best management is to insert and occlude a nephrostomy tube, apply pressure to the incision, and let the collecting system clot of

Question 13

Delayed hemorrhage is usually caused by __ or arterial __, with the latter being more common, tx

Answer 13

Delayed hemorrhage is usually caused by arteriovenous fistulas or arterial pseudoaneurysms, with the latter being more common

Both arteriovenous fistulae and pseudoaneurysms are treated with selective angioembolization

Question 14

Renal pelvic perforation is usually recognized ___. The ___ is a usual sign if the perforation is not visualized directly at first.

Answer 14

Renal pelvic perforation is usually recognized intraoperatively . Collapse of a previously distended renal pelvis is a usual sign if the perforation is not visualized directly at first.

Question 15

___ is a direct and persistent communication between the intrarenal collecting system and the intrathoracic cavity

Answer 15

Nephropleural fistula (urinothorax) is a direct and persistent communication between the intrarenal collecting system and the intrathoracic cavity

Question 16

___ should be the irrigant for percutaneous renal surgery, with the exception of___ when monopolar electrocautery is used. Irrigation with ____ during percutaneous renal surgery risks intravascular hemolysis, which can be fatal

Answer 16

Normal saline should be the irrigant for percutaneous renal surgery, with the exception of glycine or similar nonelectrolytic isotonic fluids when monopolar electrocautery is used. Irrigation with water during percutaneous renal surgery risks intravascular hemolysis, which can be fatal

Question 17

Most patients with fever after percutaneous nephrolithotomy, assuming appropriate antimicrobial prophylaxis, do not have infection Rather, the majority suffer from ___, a nonspecific immune response defined by hyperthermia/hypothermia, leukocytosis/leukopenia, tachycardia, and tachypnea, which can be caused by either infectious or noninfectious insults. Self-limited fever after percutaneous interventions without associated hemodynamic compromise can be managed ___

Answer 17

Most patients with fever after percutaneous nephrolithotomy, assuming appropriate antimicrobial prophylaxis, do not have infection (Cadeddu et al., 1998). Rather, the majority suffer from systemic inflammatory response syndrome (SIRS), a nonspecific immune response defined by hyperthermia/hypothermia, leukocytosis/leukopenia, tachycardia, and tachypnea, which can be caused by either infectious or noninfectious insults. Self-limited fever after percutaneous interventions without associated hemodynamic compromise can often be managed expectantly. Indeed, most patients in this setting can be routinely discharged without intervention or risk for unplanned readmission

Question 18

If ___ is aspirated upon initial percutaneous entry to the upper urinary tract, the safest measure is to ___ and leave a ___

Answer 18

If pus is aspirated upon initial percutaneous entry to the upper urinary tract, the safest measure is to abort the procedure and leave a nephrostomy tube for drainage.

Question 19

When there is renal loss after percutaneous renal surgery, it usually is a result of__ or the ___

Answer 19

When there is renal loss after percutaneous renal surgery, it usually is a result of disastrous vascular injury or the angioembolization used to treat hemorrhage.

Question 20

Percutaneous nephrostomy is not indicated for: a. instillation of intracavitary topical therapy for urothelial carcinoma. b. Whitaker test. c. management of fungal bezoars. d. urinary retention. e. ureteral injury. 2. Relative to retrograde

Answer 20

d. Urinary retention. Obstruction of the lower urinary tract is best treated by drainage of the bladder rather than the kidney, unless secondary obstruction of the upper tract has developed that is refractory to vesical drainage. The other indications are appropriate ones for percutaneous nephrostomy.

Question 21

Relative to retrograde ureteral stent placement, percutaneous nephrostomy

: a. has a lower success rate. b. requires less anesthesia. c. is preferred in cases of ureteral obstruction owing to malignancy. d. is less commonly complicated by bacteriuria after indwelling for 1 week. e. is associated with worse health-related quality-of-life scores.

Answer 21

b. Requires less anesthesia. Percutaneous nephrostomy can be done under local anesthesia, as opposed to retrograde ureteral stent placement, which usually requires at least intravenous sedation, and commonly general or regional anesthesia. Percutaneous nephrostomy has a greater initial success rate than retrograde ureteral stent placement, at least when the collecting system is dilated. Percutaneous nephrostomy is commonly associated with bacteriuria and has health-related quality-of-life scores that are equivalent to those associated with retrograde ureteral stent placement. Ureteral stents provide satisfactory drainage in most cases of ureteral obstruction owing to malignancy

Question 22

Which of the following is correct regarding the orientation of the kidney?

a. The right kidney is slightly cephalad to the left kidney. b. The longitudinal axis is 45 degrees from vertical, with the lower pole lateral to the upper pole. c. The longitudinal axis is 45 degrees from vertical, with the lower pole anterior to the upper pole. d. The apposition of the colon to the kidney is greatest on the left side at the upper pole. e. Immediately posterior to the kidneys are the quadratus lumborum muscle, the psoas muscle, and the diaphragm.

Answer 22

e. Immediately posterior to the kidneys are the quadratus lumborum muscle, the psoas muscle, and the diaphragm. The upper poles are anterior to attachments of the diaphragm. It is the left kidney that is slightly cephalad to the right one. The second two statements are correct, except that the angulation is 30 degrees rather than 45 degrees. The apposition of the colon to the kidney varies with location; it is greatest on the left side but at the lower rather than upper pole.

Question 23

Which of the following is correct regarding the intrarenal collecting system?

a. Paired anterior and posterior calyces enter the infundibula approximately 90 degrees from each other.
b. Compound calyces are most common in the lower pole c. Most kidneys have three distinct infundibula: the upper, middle, and lower.
d. There are 8 to 16 minor calyces.
e. There is a consistent relationship between anterior and posterior calyces and their medial-lateral position on anteriorposterior radiography

Answer 23

a. Paired anterior and posterior calyces enter the infundibula approximately 90 degrees from each other. The paired anterior and posterior calyces enter approximately 90 degrees from each other. Although compound calyces are common in the lower pole, they are almost always present in the upper pole. In approximately two-thirds of kidneys, there are only two major calyceal systems (upper and lower). There are 5 to 14 minor calyces in each kidney. Because variation is considerable, the lateral-medial orientation of the calyces on anteroposterior radiography cannot be used to reliably determine which calyces are posterior.

Question 24

To reduce the risk of infectious complications from percutaneous renal surgery: a. all patients should receive prophylactic antimicrobials. b. urine cultures should be obtained on all patients. c. urine must be sterile before the procedure. d. gentamicin is an acceptable single agent for antimicrobial prophylaxis.

Answer 24

a. All patients should receive prophylactic antimicrobials. The American Urological Association recommends periprocedural antimicrobial prophylaxis for all cases of percutaneous renal surgery. Urine cultures are considered standard only in patients where bacteriuria is likely; in other cases a screening urinalysis likely is adequate, with urine culture when the urinalysis is suspicious. The urine cannot be sterilized in some patients, especially in the presence of an externalized urinary catheter or an infected calculus, and the goal in these situations is only to suppress the bacterial count before intervention. Aminoglycosides (e.g., gentamicin) are acceptable for antimicrobial prophylaxis when combined with another agent. Ampicillin/sulbactam, first- and second-generation cephalosporins, and fluoroquinolones are acceptable single agents for antimicrobial prophylaxis

Question 25

which of the following have NOT been demonstrated in randomized controlled clinical trials to reduce pain associated with percutaneous renal access? a. Tract infiltration with local anesthetic b. Intercostal nerve block c. Thoracic paravertebral block d. Balloon dilation compared with semirigid plastic dilation of the access tract e. Smaller, compared with larger, caliber postprocedure nephrostomy tubes

Answer 25

8. d. Balloon dilation compared with semirigid plastic dilation of the access tract. There is no evidence that balloon dilation is associated with less pain compared with semirigid plastic dilation of the access tract. All of the other maneuvers have been demonstrated in randomized controlled clinical trials to reduce pain associated with percutaneous renal access.

Question 26

The “triangulation” technique for fluoroscopic percutaneous renal access:

a. increases radiation exposure to the operator’s hands compared with the “eye-of-the-needle” technique. b. cannot be performed in malrotated kidneys. c. is not as dependent on retrograde assistance as the “eye-of-theneedle” technique. d. is less suitable than the “eye-of-the-needle” technique in morbidly obese patients. e. continuously monitors depth of needle penetration

Answer 26

Continuously monitors depth of needle penetration. The “triangulation” technique monitors depth of needle placement in all fluoroscopic views, whereas the “eye-of-the-needle” technique assesses depth only at the final step. If the fluoroscopy field is collimated down and the needle is held with a hemostat, sponge forceps, or purpose-built needle holder, then radiation exposure to the operator’s hands can be avoided with both techniques. Retrograde assistance is useful with any fluoroscopic percutaneous renal access, and both techniques are more difficult in morbidly obese patients

Question 27

A postoperative nephrostomy tube: a. offers greater assurance of upper urinary tract drainage than an internal ureteral stent. b. should be placed in the dilated access site. c. does not maintain the percutaneous access tract unless >18 Fr. d. reduces postoperative bleeding. e. is associated with pain unrelated to tube diameter.

Answer 27

A. Offers greater assurance of upper urinary tract drainage than an internal ureteral stent. Drainage of upper urinary tract after percutaneous renal surgery is adequate with an internal ureteral stent in most cases (or with no tube at all in selected cases), but when hemorrhage occurs, the larger caliber of a nephrostomy tube provides better drainage of the upper urinary tract collecting system than an internal ureteral stent. The nephrostomy tube does not have to be placed in the dilated access site (i.e., it can be placed at a new site), although that is common practice. Although redilation may be required, any external nephrostomy tube maintains the percutaneous access tract. There is actually less hemorrhage when a postoperative nephrostomy tube is omitted. Most studies suggest that the pain associated with nephrostomy tubes is related to tube diameter, with smaller-caliber tubes causing less pain

Question 28

A small-caliber (8 to 18 Fr) compared with a large-caliber (20 to 24 Fr) nephrostomy tube after percutaneous renal surgery is associated with: a. equivalent pain. b. more urinary leakage. c. less postprocedure blood loss. d. less need for removal in the radiology suite. e. earlier hospital discharge.

Answer 28

d. Less need for removal in the radiology suite. The removal of larger tubes occasionally can be followed by immediate hemorrhage; this is rare with smaller tubes. Therefore large-caliber nephrostomy tubes should be removed in a radiology suite where there is the opportunity for immediate replacement of the tube. Small-caliber tubes can be removed safely at the bedside after a period of clamping to assess clinically for distal ureteral obstruction. A number of studies have compared the impact of nephrostomy tube diameter after percutaneous renal surgery. Only one study found no benefit to the smaller tube. Otherwise, consistent advantages of the small-caliber tubes were less pain, less urinary leakage, and no change in postprocedure blood loss. There is no consistent evidence that small-caliber tubes are associated with shorter duration of hospitalization compared with large-caliber tubes.

Question 29

compared with internal ureteral stents after percutaneous renal surgery, nephrostomy tubes are associated with:

a. reduced need for a second procedure for removal. b. greater technical success rate. c. greater narcotic use. d. fewer complications. e. less urinary leakage from skin entry site.

Answer 29

4. c. Greater narcotic use. Most randomized controlled trials comparing internal ureteral stents to large-caliber nephrostomy tubes after percutaneous renal surgery have shown reduced narcotic use in the stented patients. The difference is less significant when a small-caliber nephrostomy tube is used. Depending on physician preference, both internal ureteral stents (if attached to a string that exits via the flank) and small-caliber nephrostomy tubes can be removed at the bedside. Randomized controlled trials comparing internal ureteral stents to nephrostomy tubes have not revealed any difference in technical success rates, complication rates, or incidence of urinary leakage from the skin entry site.

Question 30

Following an unremarkable percutaneous nephrolithotomy, there is nonpulsatile bleeding from the tract when the sheath is removed around a 12-Fr nephrostomy tube. The next step is: a. replace the nephrostomy tube with an 18-Fr Malecot catheter. b. replace the nephrostomy tube with a ureteral stent and suture the skin. c. irrigate the nephrostomy tube. d. occlude the nephrostomy tube and apply pressure to the incision. e. replace the nephrostomy tube with a Kaye nephrostomy tamponade balloon.

Answer 30

d

Question 31

During a percutaneous resection of a 2-cm upper pole urothelial neoplasm, there is sudden hemorrhage from the resection site. The next step is: a. continue with the procedure if vision is adequate. b. insert a percutaneous nephroureteral stent. c. instill gelatin granules plus thrombin into the collecting system. d. place an 18-Fr Councill catheter with the balloon inflated at the injury site. e. prepare the patient for selective angioembolization.

Answer 31

a. Continue with the procedure if vision is adequate. If the procedure can be continued with acceptable vision, then the blood loss cannot be great. However, if vision is lost, then the procedure must be aborted. If so, then inserting and occluding a nephrostomy tube, as well as applying pressure to the incision so that the collecting system clots off, will suffice in most cases. If this is not successful, then place a Councill catheter and attempt to inflate the balloon at the injury site. Instillation of gelatin granules plus thrombin into the collecting system can create a clot that is difficult to manage. Selective angioembolization is required only when an arterial injury does not respond to less intensive management, or if the injury is obviously a significant one that will not respond to these maneuvers.

Question 32

Which of the following has NOT been reported to cause renal pelvic perforation in association with percutaneous renal surgery? a. Wire passage b. Tract dilation c. Massive hemorrhage d. Use of resectoscope e. Ultrasonic lithotripsy

Answer 32

c. Massive hemorrhage. The renal pelvis will clot off before the pressure from hemorrhage would rupture it. Any manipulation during percutaneous renal surgery can cause renal pelvic perforation

Question 33

Two days after percutaneous endopyelotomy in a 65-year-old woman, nephrostography reveals contrast entering the colon. The next step is to:

a. perform exploratory laparotomy.
b. maintain the nephrostomy tube in place and insert a ureteral stent.
c. maintain the nephrostomy tube in place and insert a colostomy tube.
d. back out the nephrostomy tube into the colon and insert a new nephrostomy tube

. e. start parenteral feeding, after appropriate tube insertions.

Answer 33

9. d. Back out the nephrostomy tube into the colon and insert a new nephrostomy tube. The main principle of care of a colon injury associated with percutaneous renal surgery is prompt and separate drainage of the colon and urinary collecting system. If detected postoperatively, the simplest management is to back the nephrostomy tube out of the kidney and into the colon to serve as a colostomy, and then obtain separate access to the upper urinary tract, with either a new percutaneous access that does not traverse the colon or a retrograde-placed ureteral stent. Parenteral feeding is usually not required, and for the typical extraperitoneal injury, open surgical repair usually is needed only if the patient develops peritonitis or sepsis

Question 34

Regarding pleural injuries in association with percutaneous renal surgery: a. access below the 12th rib results in hydropneumothorax in 1% to 2% of cases. b. supra-12th rib punctures (the 11th intercostal space) result in hydropneumothorax in 20% to 40% of cases. c. supra-11th rib punctures (the 10th intercostal space) result in hydropneumothorax in 50% to 75% of cases. d. combined with distal ureteral obstruction, a nephropleural fistula can occur. e. thoracostomy to water seal drainage and suction is recommended

Answer 34

d. Combined with distal ureteral obstruction, a nephropleural fistula can occur. Nephropleural fistula (urinothorax) is a direct and persistent communication between the intrarenal collecting system and the intrathoracic cavity, which can follow percutaneous renal access of the upper urinary tract in the setting of pleural transgression. Some degree of distal ureteral obstruction usually contributes to the problem. The rates of pleural injures for infra12th rib, supra-12th rib, and supra-11th rib punctures are approximately less than 0.5%, 5%, and 25%, respectively. Thoracostomy is not necessary for all patients with hydrothorax. If one is needed, then a small-caliber tube with a Heimlich valve is all that is required in the absence of lung injury.

Question 35

Renal arteries are ___ and result in loss of the segment of renal parenchyma they supply when occluded. Renal veins communicate with each other.

Answer 35

Renal arteries are end arteries and result in loss of the segment of renal parenchyma they supply when occluded. Renal veins communicate with each other.

Question 36

The main principle of care of a colon injury associated with percutaneous renal surgery is __. The simplest management is to back the___ out of the kidney and into the colon to serve as a___, and then obtain separate access to the upper urinary tract, either with a new ___that does not traverse the colon or with a ___

Answer 36

The main principle of care of a colon injury associated with percutaneous renal surgery is prompt and separate drainage of the colon and urinary collecting system. The simplest management is to back the nephrostomy tube out of the kidney and into the colon to serve as a colostomy, and then obtain separate access to the upper urinary tract, either with a new percutaneous access that does not traverse the colon or with a retrograde-placed ureteral stent