Obstructive & Neoplastic Conditions of the Kidney & Ureter Flashcards
What are the complications of acute ureteric obstruction?
Enlargement of the urinary tract superior to the obstruction
-dilation of renal pelvis (hydronephrosis)
What are the three parts of the ureter that can be affected, causing acute/chronic ureteric obstruction?
Luminal
Mural
Extramural
What are the luminal causes of acute/chronic ureteric obstruction?
Calculus Sloughed renal papilla Blood clot TCC of renal pelvis/ureter Bladder tumour
What are the mural causes of acute/chronic ureteric obstruction?
Ureteric stricture
Congenital pelviureteric neuromuscular dysfunction
Congenital megaureter
What are the extramural causes of acute/chronic ureteric obstruction?
Pelviureteric compression
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
What are renal calculi?
Kidney stones
Where do renal calculi form?
Collecting duct
-can be deposited anywhere from renal pelvis to urethra
What are the classic sites for renal calculi deposition?
Pelviureteric junction
Pelvic brim
Vesicoureteric junction
What are renal calculi made from?
Calcium oxalate (75%) OR
Magnesium ammonium phosphate OR
Urate
How do renal calculi present?
Renal colic (excruciating loin to groin spasms, nausea/vomiting) OR
Dull loin pain OR
UTI
What investigations are appropriate in suspected acute ureteric obstruction?
Urine MCS USS (?upper tract dilation) AXR CT Retrograde pyelogram
What are the management options for acute ureteric obstruction?
Nephrostomy -decompresses pelvicalyceal system, preserves kidney function, prevents infection Surgical management (stenting)
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
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)
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)
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
