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MD2 Surgery and Anaesthesia > Renal Stones and Urological Haematuria > Flashcards

Renal Stones and Urological Haematuria Flashcards

1
Q

What are important factors that predispose to the formation of renal stones?

A 
Urinary salts >water
- Excess of salts
- Lack of water
Crystal retention
- Many people pass small crystals
- Anatomical abnormalities
- Adherence to urothelium
FHx
Climate/geography
Diet
- Animal protein
- Refined sugar
- Lack of fibre
- Lack of water
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2
Q

What sort of renal stone is the most common?

A

Ca calculus

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3
Q

What can cause the formation of a calcium calculus?

A

Primary hyperparathyroidism
Immobilisation
Malignancy
Sarcoidosis

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4
Q

If someone presents with a renal stone, what tests should be done?

A

Serum calcium > if elevated, test for serum PTH > if elevated, test for adenocarcinoma

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5
Q

What can cause uric acid lithiasis?

A

Idiopathic
Gout
Low urine output
Myeloproliferative disease; eg: leukaemia

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6
Q

What causes cystinuria?

A

Inborn error of metabolism

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7
Q

How can cystinuria present?

A

Multiple recurrent stone episodes

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8
Q

What can cause secondary urolithiasis?

A 
Infection
Obstruction
Medullary sponge kidney - dilated renal calyces
Urinary diversion
Enteric hyperoxaluria
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9
Q

What can cause idiopathic calcium urolithiasis?

A

Hypercalciuria

Normocalciuria

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10
Q

What are the compositions of renal stones, from most to least common?

A

Ca oxalate
Ca phosphate - most commonly associated with hyperparathyroidism
Uric acid
Ca NH4MgPO2 - associated with infections that split urea; eg: Proteus
Cystine

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11
Q

What is the shape of of Ca NH4MgPO2 stones?

A

Staghorn

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12
Q

What investigation is required if someone presents with a Proteus UTI?

A

Imaging to determine if stone present

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13
Q

What is the presentation of renal calculi?

A 
Pain
- Recurrent; eg: with exercise - indicates mobile stone
- Acute obstruction
- Pelvic-ureteric junction calculus
Haematuria
Infection
Incidental
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14
Q

What is the treatment for renal calculi?

A

Observe
- Asymptomatic calyceal calculus
Unless in renal pelvis, then usually treat

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15
Q

How are renal stones imaged?

A

US for screening
X-ray for radiolucent stones
Non-contrast CT

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16
Q

How do you medically treat a renal uric acid stone?

A

Hydration
Alkalinisation
Allopurinol

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17
Q

How do you medically treat a renal cystine stone?

A

Hydration
Alkalinsation
Chelating agent; eg: penicillamine

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18
Q

What are the surgical treatments for a renal stone?

A 
Extracorporeal shockwave lithotripsy
Percutaneous nephrolithotomy
Open surgery
- Pyelolithotomy
- Nephrolithotomy
- Nephrectomy
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19
Q

What is the presentation of ureteric calculi?

A

Pain

  • Flank
  • Abdomen
  • Groin
  • Scrotum/labia
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20
Q

What are the differential diagnoses for flank pain due to pathology in the kidney?

A 
Acute obstruction due to
- Stones
- Pyelo-ureteric junction obstruction
- Clot colic
- Sloughed papilla
- Extrinsic obstruction
Pyelonephritis
- Fever
- If have UTI, may have urinary symptoms
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21
Q

What are the differential diagnoses for flank pain due to pathology intraperitoneally?

A

Gallbladder
Apendix
Bowel
Ovary

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22
Q

What are the differential diagnoses for flank pain due to pathology retroperitoneally?

A

Leaking aortic aneurysm

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23
Q

What are the differential diagnoses for flank pain due to scrotal pathology?

A

Testicular torsion

Epididymis

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24
Q

What are the investigations for ureteric stones?

A 
Urine
- Haematuria
- Infection
Imaging
- Plain x-ray
- Non-contrast CT
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25
Q

What is the management of ureteric stones?

A 
75% will pass without intervention
Passage related to
- Size <5 mm
- Site: lower >upper
- Shape: smooth >ragged
- PHx
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26
Q

What are the indications for intervention with ureteric stones?

A

Obstruction with infection/sepsis
Large calculus >6 mm
Ongoing pain
Failure to progress
Solitary kidney/bilateral ureteric calculi
Social/occupational; eg: impending travel/airline pilot

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27
Q

What are the surgical interventions available for the removal of ureteric stones?

A

Nephrostomy drainage
Ureteric stent
Extracorporeal shockwave lithotripsy
Ureteroscopy with fragmentation

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28
Q

What source is indicated in macroscopic haematuria?

A 
Initial (at start of stream)
- Urethral/prostate
Terminal (starts near end of stream)
- Bladder neck
Total
- Bladder
- Ureter
- Kidney
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29
Q

If clots are present in haematuria, what source is indicated by their shape?

A

Round - bladder

Wormlike - kidney/ureter

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30
Q

If pain is associated with haematuria, what source is indicated by where the pain is?

A

Flank - kidney/ureter

Suprapubic - bladder

31
Q

What urinary symptoms can be associated with haematuria?

A

Dysuria

Frequency

32
Q

What are the investigations for haematuria?

A 
Urine
- Microscopy
   - RBC morphology
      - Misshapen - glomerular
      - Fairly regular - non-glomerular
   - Protein casts
- Cytology - test urine for malignant cells - specific for transition cell carcinoma
- Culture
Imaging
- US urinary tract
- CT urogram
Endoscopy
- Cystoscopy
- +/- retrograde pyelogram
- Ureteropyeloscopy +/- biopsy
33
Q

What is the best imaging for haematuria?

A

CT urogram - do pre- and post-contrast

Picks up any collecting defects/masses

34
Q

What are pre-renal causes of haematuria?

A

Coagulopathy

35
Q

What are renal parenchymal causes of haematuria?

A

Glomerulonephritis
Renal neoplasm
Trauma

36
Q

What are causes of haematuria in the renal collecting system?

A

Transitional cell carcinoma
SCC - much less common
Calculus
Infection

37
Q

What are causes of haematuria in the ureters?

A

Transitional cell carcinoma

Calculus

38
Q

What are the causes of haematuria in the bladder?

A

Transitional cell carcinoma
Cystitis
Calculus
Trauma

39
Q

What is the most common cause of haematuria?

A

Cystitis

40
Q

What findings indicate cystitis as the cause for haematuria?

A

+ve urine culture

Usually have other urinary symptoms

41
Q

What are the causes of haematuria in the urethra?

A

Stricture

Infection

42
Q

What is the most common cancer of the kidney?

A

Renal cell carcinoma

43
Q

From where does renal cell carcinoma arise?

A

Parenchyma, usually proximal tubule

44
Q

What is the presentation of renal cell carcinoma?

A 
Incidental - most common presentation
Classic triad - rarely seen
- Haematuria
- Mass
- Pain
Systemic symptoms
- Weight loss
- Appetite loss
Metastatic disease
- Bone
- Lung
- Liver
- Brain
Paraneoplastic syndrome
- Hypercalcaemia
- HTN
- Pyrexia
- Hepatoxicity - abnormal LFTs
Haematological
- Anaemia
- Polycythaemia
IVC obstruction
- Local extension of tumour
- Lower limb oedema
- Varicocoele
45
Q

What is the treatment for renal cell carcinoma?

A 
Surgical, if
- Primary disease
- Single metastasis
Medical, if
- Palliation of metastatic disease
Radiation, if
- Palliation of metastatic disease
46
Q

What are the surgical option for the treatment of renal cell carcinoma?

A 
Radical nephrectomy
- Removal of contents of Gerota's fascia = 
   - Kidney
   - Adrenal gland
   - Perinephric fat
Partial nephrectomy
- Preferred, especially if small, incidental finding
- Performed if
   - Solitary kidney
   - Poorly functioning contralateral kidney
   - Bilateral tumours
   - Small peripheral tumours
47
Q

What is the medical treatment for renal cell carcinoma?

A

Tyrosine kinase inhibitor; eg: sunitinib

48
Q

What sort of metastases is radiotherapy especially good for, in renal cell carcinoma?

A

Bony/soft tissue mets

49
Q

From where can transitional cell carcinoma arise?

A

Renal pelvis
Ureter
Bladder/prostatic urethra

50
Q

What are the risk factors for transitional cell carcinoma?

A 
Cigarette smoking
Industrial exposure
- Dyes
- Leather
- Rubber
- Hydrocarbons
Papillary necrosis
Pelvic radiotherapy
Cyclophosphamide
Field effect = transitional cell carcinoma elsewhere in urinary tract
FHx
51
Q

What is cyclophosphamide?

A

Cytotoxic drug used in some malignancies and autoimmune conditions

52
Q

What is the epidemiology of transitional cell carcinoma in the renal pelvis?

A

M:F = 3:1

53
Q

What is the presentation of transitional cell carcinoma in the renal pelvis?

A

Haematuria
Pain
Mass

54
Q

How is transitional cell carcinoma in the renal pelvis diagnosed?

A 
CT urogram
- Filling defect
- Dilatation/non-function
- Parenchymal invasion of mass
Retrograde pyelogram
- Cytology
- Lavage
- Brush biopsy
Ureterorenoscopy
- Direct visualisation
- Biopsy
55
Q

What is the treatment for transitional cell carcinoma in the renal pelvis?

A

Nephro-ureterectomy and cuff of bladder removal
Surveillance cytoscopy
- 35% risk of bladder transitional cell carcinoma

56
Q

What is the presentation of transitional cell carcinoma in the ureter?

A

Haematuria

Flank pain

57
Q

How is transitional cell carcinoma in the ureter diagnosed?

A 
CT urogram
- Filling defect
- Hydronephrosis/non-function
Retrograde pyelograpm
Cytology
Ureteroscopy > biopsy
58
Q

What is the treatment for transitional cell carcinoma in the ureter?

A

Nephro-ureterectomy, including cuff of bladder
Segmental lower ureterectomy
Surveillance cystoscopy

59
Q

What is the T staging for transitional cell carcinoma in the bladder?

A 
Ta = mucosa
T1 = sub-mucosa
T2 = muscle
T3 = extravesical fat
T4 = adjacent organs
60
Q

What are the different grades of transitional cell carcinoma in the bladder?

A 
Low grade
High grade
Carcinoma in situ = high grade
- Usually quite flat
- If untreated, progresses to invasive disease
- Needs aggressive treatment
61
Q

What is the presentation of transitional cell carcinoma in the bladder?

A 
Painless haematuria
Symptoms of cystitis
- In absence of infection
- Recurrent infection
Incidental
62
Q

How is transitional cell carcinoma in the bladder diagnosed?

A

US
CT urogram
Urine cytology
Cystoscopy/resection biopsy - into bladder wall to try and get some muscle

63
Q

What is the treatment for transitional cell carcinoma in the bladder that has not invaded the muscle?

A 
Transurethral resection of bladder tumour
- Curative for grades 1 and 2
- 75% recur
- Surveillance cystoscopy
Multiple/frequent recurrences
- Intravesical therapy
   - BCG
   - Mitomyic
   - Adriamycin
   - Thiotepa
64
Q

What is the treatment for carcinoma in situ, or high grade superficial transitional cell carcinoma in the bladder?

A

Intravesical BCG weekly for 6 weeks

If fail local therapy, high risk of progression to muscle invasion > radical cystectomy

65
Q

What is the treatment for transitional cell carcinoma in the bladder that has invaded the muscle?

A

Transurethral resection of bladder tumour for diagnosis
Staging
- CT abdomen
- CXR
Radical cystectomy and ileal conduit/neobladder
Radiotherapy
Chemotherapy with cis-platinum based drugs

66
Q

What are the acute investigations performed when someone presents with renal stones?

A 
FBE
UEC
Creatinine
Serum Ca and uric acid
MSU
CT-KUB
X-ray KUB
67
Q

What is the acute management for renal stones?

A 
Pain relief
- NSAIDs
- Opioids
- Paracetamol
Hydration
Does patient need acute intervention?
- Yes > admission
- No > surveillance
68
Q

Is obstructive pyelonephritis a urological emergency?

A

Yes

69
Q

What organism usually causes obstructive pyelonephritis?

A

Gram negative bacteria; eg: E coli

70
Q

What is a complication of obstructive pyelonephritis?

A

Systemic inflammatory response syndrome/shock

71
Q

What is thee management of obstructive pyelonephritis?

A 
IV Abs, covering Gram -ves and Enterococcus
Urgent decompression
- Nephrostomy
- Stent
Supportive care
- Fluids
- Monitoring
- ICU if necessary
72
Q

What are the medical expulsive therapies available for the management of renal stones?

A 
Alpha-blockers - relax ureteric wall
- Increase stone passage
- Decrease time to stone passage by 2-4 days
- Decrease pain
Eg: tamsulosin
73
Q

How do you prevent renal stone recurrence?

A 
Adequate fluid intake
Dietary modification
Urinary alkalinisation
Medical therapy
- Allopurinol
- Thiazide diuretics
74
Q

What can cause a false positive dipstick in haematuria?

A

Myoglobinuria

MD2 Surgery and Anaesthesia (31 decks)

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