Kidneys and Bladder Flashcards
Anatomy of kidneys- where are they?
Retroperitoneal
Surrounded by Gerota’s fascia
Lateral to psoas muscles
Inferior to the posterior diaphragm
Blood supply to/from kidneys
Renal arteries
Veins drain into IVC
Path of ureters
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
Where is the bladder and what is its blood supply?
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.
What is the nerve supply to the bladder?
Sympathetic nerves: from L1 and L2 roots
Parasympathetic nerves: from S2, S3, S4.
What are kidney stones made of?
Most (80%) are made of calcium phosphate and calcium oxalate.
15% struvite
5% uric acid
1% cystine
What are calcium stones caused by?
Usually idiopathic
Can be dt hyperuricosuria and hyperparathyroidism (so ck PTH levels just in case)
What are struvite stones caused by?
Infection with urease-producing organisms- esp Proteus.
T/F cystine stones are hereditary
True
Uric acid stones are common in which pts?
Pts w gout
Also Lesch-Nyhan syndrome
and tumors
Which kinds of stones are more common in women? in men?
Calcium, struvite- women
Uric acid- men
Cystine- equal
What kinds of dietary factors are related to stones?
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
Pt px of stones
Acute onset of pain in flank, radiating to groin
Unable to find comfy position
Vomiting
Dysuria, frequency, hematuria
Dx Eval for stones
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
What does it mean if there are fluid jets at the entrance of the ureter into the bladder on US?
Total obstruction
Dumbell shaped stones
Calcium oxalate
small, red-orange stones
Uric acid
Bipyramidal stones
calcium oxalate
birefringent stones
calcium oxalate
flat, hexagonal, yellow stones
cystine
rectangular prism stones
struvite
Rx for stones
control pain with narcotics, nausea w antiemetics.
most stones pass spontaneously.
What drugs can be given to facilitate stone passage?
Deflazacort (glucocorticoid)
Nifedipine (CCB)
Tamsulosin (alpha blocker)
What size of stones don’t require intervention?
Asx stones 5mm, consider intervention.
Minimally invasive options for stones
ESWL
PCNL
Endoscopic lithotripsy (using US, electrohydraulic, or laser)
ESWL
extracorporeal shock wave lithotripsy
gives high energy shock waves, causing stone fragmentation
Not good for struvite or staghorn calculi
PCNL
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)
How to prevent recurrent stones?
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)
Kind of renal cancer
granular cell
tubular adenocarcinoma
Wilms tumor
sarcoma
HPE for renal ca
Hematuria and flank pain
can be sudden in event of hemorrhage
If mets, can have fever and extrarenal pain
Can palpate some tumors
Dx eval for renal ca
IV pyelography- shows defect in renal silhouette.
CT- shows difference bt cystic and solid lesions
Rx for renal ca
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.
Kinds of bladder ca
Transitional cell tumors - 90%
otherwise, squamous or adenocarcinoma
Predisposing factors for bladder ca
Smoking
beta-naphthylamine (Azo dyes)
paraminophenol (?)
Px of pt w bladder ca
hematuria
UTIs
bladder irritability- frequency, dysuria
Dx eval for bladder ca
Urinary cytology
Cystoscopy w biopsy confirms dx
Excretory urography demonstrates lesion
Rx for bladder ca
Local dz- transurethral resection w chemo (doxorubicin, mitomycin C, thiotepa)
Locally advanced- radical cystectomy (incl prostatectomy) +rads +chemo (gemcitabine and cisplatin)
