Kidneys and Bladder

Question 1

Anatomy of kidneys- where are they?

Answer 1

Retroperitoneal
Surrounded by Gerota’s fascia
Lateral to psoas muscles
Inferior to the posterior diaphragm

Question 2

Blood supply to/from kidneys

Answer 2

Renal arteries

Veins drain into IVC

Question 3

Path of ureters

Answer 3

go retroperitoneally, dorsal (behind) the cecum on the right and the sigmoid on the left.
Cross iliac vessels at the bifurcation bt internal and external
Enter the true pelvis and empty into bladder

Question 4

Where is the bladder and what is its blood supply?

Answer 4

Bladder is below the peritoneum in the true pelvis. Covered by a fold of peritoneum.
Blood supply is from iliac arteries, thru the superior, middle and inferior vesical arteries.

Question 5

What is the nerve supply to the bladder?

Answer 5

Sympathetic nerves: from L1 and L2 roots

Parasympathetic nerves: from S2, S3, S4.

Question 6

What are kidney stones made of?

Answer 6

Most (80%) are made of calcium phosphate and calcium oxalate.
15% struvite
5% uric acid
1% cystine

Question 7

What are calcium stones caused by?

Answer 7

Usually idiopathic

Can be dt hyperuricosuria and hyperparathyroidism (so ck PTH levels just in case)

Question 8

What are struvite stones caused by?

Answer 8

Infection with urease-producing organisms- esp Proteus.

Question 9

T/F cystine stones are hereditary

Answer 9

True

Question 10

Uric acid stones are common in which pts?

Answer 10

Pts w gout
Also Lesch-Nyhan syndrome
and tumors

Question 11

Which kinds of stones are more common in women? in men?

Answer 11

Calcium, struvite- women
Uric acid- men
Cystine- equal

Question 12

What kinds of dietary factors are related to stones?

Answer 12

Low fluid intake- general risk factor
High salt- promote excretion and incrsd urinary conc of calcium
HIgh animal protein- increased Ca2+, uric acid, citrate, acid excretion
Low calcium diet- increase oxalate excretion

Question 13

Pt px of stones

Answer 13

Acute onset of pain in flank, radiating to groin
Unable to find comfy position
Vomiting
Dysuria, frequency, hematuria

Question 14

Dx Eval for stones

Answer 14

Look at urinary sediment- shows hematuria, crystals. Imp to determine which kind of stone!
Blood work- elevated serum Ca2+ and uric acid
Measure PTH in pts w hypercalcemia or high urinary Ca2+
Abd XR- stones are radiopaque
IV pyelography- outlines defects in ureter/shows obstructions, dt stones
Retrograde pyleography (inject thru urethra) can show obstruction
US of kidneys- shows show, hydronephrosis

Question 15

What does it mean if there are fluid jets at the entrance of the ureter into the bladder on US?

Answer 15

Total obstruction

Question 16

Dumbell shaped stones

Answer 16

Calcium oxalate

Question 17

small, red-orange stones

Answer 17

Uric acid

Question 18

Bipyramidal stones

Answer 18

calcium oxalate

Question 19

birefringent stones

Answer 19

calcium oxalate

Question 20

flat, hexagonal, yellow stones

Answer 20

cystine

Question 21

rectangular prism stones

Answer 21

struvite

Question 22

Rx for stones

Answer 22

control pain with narcotics, nausea w antiemetics.

most stones pass spontaneously.

Question 23

What drugs can be given to facilitate stone passage?

Answer 23

Deflazacort (glucocorticoid)
Nifedipine (CCB)
Tamsulosin (alpha blocker)

Question 24

What size of stones don’t require intervention?

Answer 24

Asx stones 5mm, consider intervention.

Question 25

Minimally invasive options for stones

Answer 25

ESWL
PCNL
Endoscopic lithotripsy (using US, electrohydraulic, or laser)

Question 26

ESWL

Answer 26

extracorporeal shock wave lithotripsy
gives high energy shock waves, causing stone fragmentation
Not good for struvite or staghorn calculi

Question 27

PCNL

Answer 27

percutaneous nephrolitholotomy
put in nephrostomy tube
better than ESWL for large, complex stones or stones made of cystine.
(but PCNL and ESWL can be combined)

Question 28

How to prevent recurrent stones?

Answer 28

Increase fluid intake
Dietary mod’s dep on stone type
Thiazide diuretic for pts w hypercalcuria
allopurinal for potassium citrate for uric acid stones
can also give K+ citrate for hypocitraturia
give calcium if urinary ca2+ is low low (for oxalate)

Question 29

Kind of renal cancer

Answer 29

granular cell
tubular adenocarcinoma
Wilms tumor
sarcoma

Question 30

HPE for renal ca

Answer 30

Hematuria and flank pain
can be sudden in event of hemorrhage
If mets, can have fever and extrarenal pain
Can palpate some tumors

Question 31

Dx eval for renal ca

Answer 31

IV pyelography- shows defect in renal silhouette.

CT- shows difference bt cystic and solid lesions

Question 32

Rx for renal ca

Answer 32

radical nephrectomy, try to remove all of tumor
for mets, chemo doesn’t work too well.
Gemcitabine and flurouracil show limited activity
IL-2 can be used.

Question 33

Kinds of bladder ca

Answer 33

Transitional cell tumors - 90%

otherwise, squamous or adenocarcinoma

Question 34

Predisposing factors for bladder ca

Answer 34

Smoking
beta-naphthylamine (Azo dyes)
paraminophenol (?)

Question 35

Px of pt w bladder ca

Answer 35

hematuria
UTIs
bladder irritability- frequency, dysuria

Question 36

Dx eval for bladder ca

Answer 36

Urinary cytology
Cystoscopy w biopsy confirms dx
Excretory urography demonstrates lesion

Question 37

Rx for bladder ca

Answer 37

Local dz- transurethral resection w chemo (doxorubicin, mitomycin C, thiotepa)
Locally advanced- radical cystectomy (incl prostatectomy) +rads +chemo (gemcitabine and cisplatin)