Obstructive & Neoplastic Conditions of the Kidney & Ureter Flashcards by Jack Gorard

What are the complications of acute ureteric obstruction?

Enlargement of the urinary tract superior to the obstruction

-dilation of renal pelvis (hydronephrosis)

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What are the three parts of the ureter that can be affected, causing acute/chronic ureteric obstruction?

Luminal
Mural
Extramural

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What are the luminal causes of acute/chronic ureteric obstruction?

Calculus
Sloughed renal papilla
Blood clot
TCC of renal pelvis/ureter
Bladder tumour

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What are the mural causes of acute/chronic ureteric obstruction?

Ureteric stricture
Congenital pelviureteric neuromuscular dysfunction
Congenital megaureter

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What are the extramural causes of acute/chronic ureteric obstruction?

Pelviureteric compression

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What are the Sx/signs of acute/chronic ureteric obstruction

Varying loin pain (greater w/ urine volume)
Anuria (bilateral blockage)
Polyuria (partial blockage causing renal failure)
Loin tenderness
Palpable hydronephrotic kidney

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What are renal calculi?

Kidney stones

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Where do renal calculi form?

Collecting duct

-can be deposited anywhere from renal pelvis to urethra

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What are the classic sites for renal calculi deposition?

Pelviureteric junction
Pelvic brim
Vesicoureteric junction

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What are renal calculi made from?

Calcium oxalate (75%) OR
Magnesium ammonium phosphate OR
Urate

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How do renal calculi present?

Renal colic (excruciating loin to groin spasms, nausea/vomiting) OR
Dull loin pain OR
UTI

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What investigations are appropriate in suspected acute ureteric obstruction?

Urine MCS
USS (?upper tract dilation)
AXR
CT
Retrograde pyelogram

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What are the management options for acute ureteric obstruction?

Nephrostomy
   -decompresses pelvicalyceal system, preserves kidney function, prevents infection
Surgical management (stenting)

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What are the risk factors for renal calculi?

15% lifetime risk
20-40yrs
3:1 male preponderance
Obesity
Dehydration/llow fluid intake
Family/personal hx
Anatomical abnormalities

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What investigations are appropriate in suspected renal calculi?

Bloods (Ca, PO4, G6, HCO3, urate)
Urine dip (95% +ve for blood)
Pregnancy test
Urine MCS
AXR (80% calculi visible)
Non-contrast CT (99% calculi visible)

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What are the acute management options for renal calculi?

A-E resus
75mg diclofenac IM
IV metoclopramide (if N/V)
IV a/b (if infec)
Assess for admission/active treatment (surg)

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What factors indicate hospital admission in renal calculi pts?

Severe pain at 1hr
Risk of AKI
Signs of shock/infection
Uncertainty over dx

What are the indications for active treatment of renal calculi?

Low chance of spontaneous passage (>10mm)
Persistent pain
Ongoing obstruction
Signs of infec
Renal insufficiency

What are the conservative (medical) options for managing renal calculi?

Tamsolusin (1st line) OR Nifedipine (inc rate of spontaneous expulsion)
Advice on discharge
-80% pass naturally
-high fluid intake
-return if increase in pain/signs of infec
-if 1st stone catch in sieve for analysis
Refer to urology w/i 1wk

What are the active (surgical) options for managing renal calculi?

Extracorporeal shockwave lithotripsy (ESWL)
Uretoscopy
Percutaneous nephrolithotomy

Describe Extracorporeal Shocwave Lithotripsy (ESWL)

Outpt procedure focusing shockwaves on stone to break it up and allow spontaneous passage
-if hydonephrosis present may need percutaneous nephrostomy

What is Wilm’s Tumour?

Undifferentiated mesodermal tumour

20% of childhood malignancies

How does Wilm’s Tumour present?

3.5yrs w/ flank pain & abdo mass

What are the management options for Wilm’s Tumour?

DO NOT BIOPSY

Nephrectomy & pre-op chemo

What are Renal Cell Carcinomas?

Vascular tumours arising from proximal tubular epithelium

What are the risk factors for RCCs?

90% of renal tumours | Prolonged haemodialysis main risk factor (15%)

How do RCCs present?

``` 50% incidental 10% w/ classic triad of sx -haematuria -loin pain -abdo mass + B sx Varicoele (if invasion of L renal vv) Polycythaemia/HTN (if renin/EPO secretion) ```

How should suspected RCCs be investigated?

``` Urine cytology USS (solid/cystic) CT/MRI CXR Renal angiography ```

What are the management options for RCCs?

``` Radical nephrectomy Partial nephrectomy -if peripheral tumours <5cm -if bilat tumours OR contralateral poor kidney func Post-op chemo ```

What is the prognosis of RCCs?

65% 5yr survival if N0 25% if nodal involvement 5% if distant mets

What are the common causes of renal cysts?

``` Solitary/multiple cysts occur commonly in the elderly -50% by 50yrs Polcystic kidney disease Medullary cystic disease Medullary sponge kidney ```

How do solitary/multiple cysts in the elderly present?

Often asymptomatic OR | Haematuria/pain

What are Transitional Cell Carcinomas?

Carcinoma of transitional cell epithelium | -most commonly bladder (50x more common)

What structures are lined by transitional cell epithelium?

``` Calyces Renal pelvis Ureter Bladder Urethra ```

What are the risk factors for TCCs?

Smoking Aromatic amines (rubber/plastic/dye industry workers) Chronic cystitis Pelvic irradiation

How do TCCs present?

Painless haematuria +/- clots Recurrent UTI Voiding sx Pain from local invasion

What investigations are appropriate in suspected TCC?

Urine MCS/cytology (?sterile pyuria) Cystoscopy/biopsy (gold standard) CT/MRI or lymphangiography

What are the management options for carcinoma in situ/T1 bladder carcinomas?

Transurethral resection of bladder tumour - at cystoscopy w/ intravesical chemo - 5yr survival 95%

What are the management options for T2/T3 TCC?

Radical cystectomy w/ pre-op chemo | -ileal conduit used to leave urostoma

What are the management options for T4 TCC?

Palliative treatment

What long term management is required for all TCCs?

Long term follow up w/ cystoscopy

Describe squamous cell carcinoma of the bladder

Rarer, present similarly to TCC | Risk factors - anything that irritates the bladder lining