Obstructive and Neoplastic Conditions of the Kidney and the Ureter Flashcards
Describe the causes of ureteric obstruction?
Intraluminal:
- Caliculi
- Embolism
- Sloughed renal papilla (ATN)
- TCC of renal pelvis or ureter
Mural:
- Tumour
- Ureteric stricture (congenital, post calculus, post surgery, TB)
- Neuromuscular (MS)
Extramural:
- AAA
- Diverticulitis
- Pregnancy
- External tumours
Describe the signs, symptoms and complications of ureteric colic?
Signs and Symptoms:
Severe Flank/Loin Pain (may be colicky or constant)
May radiate to ilica fossas, inguinal areas or testes.
Haematuria (85%)
May have palpable hydronephrotic kidney
Anuria if complete obstruction
Complications:
Hydronephrosis > renal necrosis
Stasis of urine leading to pyelonephritis
What are renal calculi predominantly made of and what are risk factors for there development?
Renal calculi are mostly made of calcium phosphate, some are magnesium and urate based
Risk factors include:
- high serum Ca
- hyperparathyroidism
- alkaline urine (from bacteria)
- FHx
- Anatomical abnormalities e.g. horseshoe kidney
- Crohns
- Medications (vit D and calcium supplements)
- dehydration (outdoor active job)
- male. Most likely age to present is between 35-45.
- gout
Describe the investigations which should be done in a patient with suspected ureteric obstruction?
Bedside:
- Urinalysis
- MCS if ? infection
- bHCG to rule out ectopic pregnancy
Bloods:
- FBC (looking for anaemia ?CKD, raised WCC ?infection)
- UE’s
- Serum Ca, Ph, and urate (if caliculi are suspected)
Imaging:
- Renal US
- AXR/CT KUB (non contrast)
How should you initially manage a patient acutely with ureteric caliculi?
Initially control pain using: -IM diclofenac -Consider buscopan as a muscle relaxant Other considerations: -IM metoclopramide if severe N+V -IV fluids if no oral intake -IV Abx if signs of an infection
How should a patient with ureteric calculi be managed conservatively?
Conservative management involves letting the stone pass spontaneously usually takes 1-3 weeks. (80% pass naturally)
Conservative management can be used for up to 3 weeks if the patient can tolerate the pain (with analgesia)
The progress can be monitored with imaging if symptoms persist.
Patient should be counselled to drink lots of fluid and come back if there are any symptoms of infection or obstruction.
Can give tamsolusin (but don’t really use any more)
What are the non conservative methods of managing a patient with ureteric caliculi?
If ureter is blocked or fear that it may become blocked:
A JJ stent is inserted via a cystoscope to keep thev ureter patent to buy time.
Procedures to remove stones include:
- Extracorporeal shock wave lithotripsy (ESWL) - shock waves are directed over the stone to break it apart. The stone particles will then pass spontaneously.
- Percutaneous nephrolithotomy (PCNL) - used for large stones (greater than 2 cm). Stones are removed at the time of the procedure using a nephroscope.
- Ureteroscopy - this involves the use of laser to break up the stone.
- Open surgery - rarely necessary and usually reserved for complicated cases or for those in whom all the above have failed - eg multiple stones
Sometimes stent ureters post surgery to help the passage of the stone!
How does chronic ureteric obstruction present?
Flank or abdominal pain.
And/Or
CKD
+/- polyuria
What is the tissue of origin of a Wilm’s tumour?
It is an undifferentiated mesodermal malignancy affecting the kidney in children.
It is also known as a nephroblastoma.
What are the presenting features of a Wilm’s tumour and how is it treated?
Usually an asymptomatic abdominal mass.
May present with:
- Abdo pain
- Haematuria
- UTI’s
It is treated with a nephrectomy followed by chemotherapy (usually curative). Do not biopsy them
In large tumours which are not resectable there may perform preoperative chemo.
What are the common associations with Wilm’s tumour?
Overgrowth syndromes (Beckwith-Wiedemann syndrome + others)
Trisomy 18 (Edwards)
Wilms’ with Aniridia, Gonadoblastoma (GU malformations), and Retardation (WAGR).
Can have Familial Wilms Tumour, autosomal dominant transmission (very rare)
Describe the presenting symptoms of renal carcinoma in adults?
Often presents quite late.
General:
Malaise
Weight loss
Anaemia* (EPO suppression, can also have polycythaemia if paraneoplastic)
Renal:
- Painless haematuria (most common)
- Mass in flank
- Pain
- Hypertension (renin over secretion)
- Hypercalcaemia (paraneoplastic secondary to a parathyroid like hormone)
- Varicocele (erodes into local veins)
What is the most common type of renal Ca in children and adults?
Renal cell carcinoma (also known as adenocarcinoma of the kidney). Prognosis is not bad, 5 year 60-70%.
In children: Wilm’s tumour
Note:
The other main type is transitional cell carcinoma. Benign tumours are rare.
What are the risk factors for developing renal Ca?
Genetics
Modifiable: Smoking Obesity HTN Cadamine (found in dark chocolate)
Renal: PCKD (polycystic kidney) Long-term renal dialysis Tuberous sclerosis Renal transplant recipients Acquired renal cystic disease
What is the route of spread in renal tumours?
Where does it commonly met to?
Usually spreads locally through the renal capsule and into surrounding structures:
- Lymph nodes
- Abdominal organs (adrenal glands, liver, spleen, colon or pancreas)
Systemic spread: via the renal vein and IVC.
Most common site of distant metastases is to the lungs where there are classical cannonball lesions.
Also spreads to bone causing osteolytic lesions.
