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Surgery > Renal system > Flashcards

Renal system Flashcards

1
Q

Causes of hematuria

A

> Trauma

  • Urinary catheterisation
  • Flexible cystoscopy
  • Post-TURP

> Infection

  • Tuberculosis
  • Cystitis
  • Prostatitis
  • UTI

> Tumor

  • Transitional cell carcinoma (bladder, ureter)
  • BPH

> Stones

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2
Q

Most common site of bladder Ca

A

Most bladder cancers start in the innermost lining of the bladder, which is called the urothelium or transitional epithelium.

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3
Q

Imaging found suspicious lesion at bladder, next step?

A

Flexible/ Rigid cystoscopy KIV Transurethral Resection of Bladder Tumor (TURBT)

  • Diagnostic, therapeutic and staging
  • Direct visualize + Cell brushing and biopsy
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4
Q

Renal vs Bladder Ca in history

A

> Renal
- Triad: flank pain, painless hematuria, palpable flank mass

> Bladder

  • Persistent painless hematuria
  • Irritative symptoms
  • Obstructive symptoms
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5
Q

Diagnostic investigation bladder Ca

A
  • Urine cytology for malignant cells
  • IVU/ CT
  • Flexible cystoscopy + cell brushing and cytology
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6
Q

Management for bladder Ca

A

> Superficial (T1)

  • TURBT
  • Intravesical therapy (eg: BCG)

> Muscle invasive (T2 and above)
- Radical cystectomy with urinary diversion (eg: ileal conduit)

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7
Q

Risk factor bladder Ca

A
  • Male, Age>50
  • Occupational exposure to aromatic amine (eg: printing, plastic industries)
  • Cigarette smoking
  • Chronic cystitis
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8
Q

Type of bladder Ca

A
  • Transitional cell carcinoma (>90%)
  • SCC (7-9%; long term catheter, untreated bladder stone)
  • Adenocarcinoma (1%)
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9
Q

Describe ileal conduit

A
  • Segment of ileum is selected (avoid terminal 15cm to maintain absorption of bile salt, Vit B12, and fat soluble vitamins)
  • The ureters are implanted into it, ileum brought to skin surface, and stoma is created
  • Urine will drain from kidneys through ureter into the piece of ileum and collected in an external bag
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10
Q

How to differentiate renal and gallstone in X-ray

A
  • Do lateral X-ray and the gallstone will be in front of the kidney
  • Gallbladder is an intraperitoneal organ while kidney is a retroperitoneal organ
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11
Q

Management for urolithiasis

A

> Conservative (<5mm)

  • Pain control
  • Daily alpha blocker therapy
  • High fluid intake
  • Diet modification
  • Chemical dissolution

> Surgical (>10mm)

  • ESWL
  • PCNL
  • Open surgery (eg: pyelolithotomy, ureterolithotomy)

> Adjuncts
- Double J-stent

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12
Q

Mechanism of ESWL

A
  • High-energy shock waves transmitted through water and focused on the stone
  • The change in tissue density between the soft kidney tissue and hard stone cause release of energy at the stone surface
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13
Q

Complication of ESWL

A
  • Ureteral blockage due to stone fragment
  • Urinary tract infection
  • Transient hematuria
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14
Q

Presentation of stone at different site: kidney, ureter, bladder

A

> Renal stone
- Vague flank pain

> Ureteric stone

  • Intermittent loin to groin pain
  • Hematuria
  • Frequency, urgency, dysuria

> Bladder stone

  • Frequency, urgency
  • Hematuria
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15
Q

Type of urinary calculi

A
  • Calcium Oxalate (75%) [sharp projection, alkaline urine]
  • Struvite (15%)
    [strongly alkaline urine, eg: staghorn calculus]
  • Urate (5%)
    [Acid urine, radiolucent]
  • Cysteine (2%)
    [Acid urine and metabolic origin]
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16
Q

Cause of renal calculi

A
  • Supersaturation
  • Infection (eg: struvite stone/ magnesium ammonium phosphate in Proteus vulgaris infection - splits urea into ammonium, generating alkaline urine)
  • Drug-induced
17
Q

Management renal cell carcinoma

A

> Surgery +- adjuvant chemotherapy

  • Partial nephrectomy (T1 <7cm)
  • Total nephrectomy (>=T2, >7cm)
  • Radical nephrectomy (>=T2)
18
Q

Significant of Nitrate in urine

A
  • Detect products of nitrate reductase, which produced by urease-splitting organisms
  • Eg: Proteus species, E. coli
  • However, negative in Enterococcus infection
19
Q

Complication of PNL (for stones >20mm or staghorn stones)

A
  • Significant bleeding (8%)
  • Renal pelvis perforation (3%)
  • Hydrothorax (2%)
  • Septic shock (2.4%)
20
Q

Cause of hypercalcemia

A

> Most common (>90%)

  • Primary hyperparathyroidism
  • Malignancy (eg: bone metastasis, multiple myeloma)

> Other

  • Increase calcium intake
  • Hypervitaminosis D
21
Q

Cause of hyperparathyroidism

A

> Primary

  • Parathyroid adenoma/ carcinoma
  • Hyperplasia

> Secondary

  • Vit D deficiency
  • Decrease calcium intake
  • Chronic renal failure
22
Q

Investigation for primary hyperparathyroidism

A
  • Serum calcium (confirm the hypercalcemia)
  • Serum PTH
  • 24 hour urinary calcium
  • Serum 25-hydroxyvitamin D (Differentiate of secondary hyperparathyroidism due to Vit D deficiency from Primary Hyperparathyroidism)
23
Q

Common pathogen in UTI

A
  • E. coli (Most common)
  • Enterobacteriaceae (eg: Klebsiella, Proteus spp)
  • Pseudomonas
  • Staphylococci
24
Q

Pre-procedure assessment for IV Urogram

A
  • BUSE/ Cr to assess renal function
  • As it required contrast administration.
  • Non-contrast CT is use more often to assess renal stone
25
Q

Pathophysiology of irritative symptoms

A
  • Stone tend to lodge at site of ureter narrowing, eg: uretero-pelvic/ vesical junction
  • Irritation of the trigon can trigger urination and irritation symptoms
26
Q

Cause of unilateral vs bilateral hydronephrosis

A

> Unilateral

  • Ureteric stone
  • Bladder tumor (at ureterovesical junction)
  • Enlarge LN
  • Blood clot

> Bilateral

  • BOO (eg: BPH)
  • Bladder tumor (at outlet)
  • Neurogenic bladder
27
Q

Classify hematuria

A
  • Gross vs Microscopic
  • Painful vs Painless
  • Initial vs Mixed vs Terminal
28
Q

Investigation for urolithiasis

A
  • FBC
  • Serum uric acid
  • UFEME
  • CT Urogram
  • KUB x-ray
  • Ultrasound kidney/ bladder
29
Q

Complication of urolithiasis

A
  • Ureteral scarring and stenosis
  • Urosepsis
  • Infected hydronephrosis
  • Chronic pyelonephritis
  • Acute and chronic renal failure
30
Q

ESWL vs PCNL

A

> ESWL

  • Preferred for stone <10mm
  • Outpatient procedure

> PCNL

  • Preferred for stone >20mm
  • Prolonged hospital stay
  • Higher stone clearance rate
31
Q

4 differential for radio opaque shadow at left lumbar region

A
  • Cholelithiasis overlying right kidney
  • Renal artery calcification
  • Phleboliths
  • Calcified mesenteric LN
32
Q

Indication of emergency surgical intervention in stone disease

A
  • Obstructing stone + suspected/ confirmed UTI
  • Mx: Ureteral stent/ percutaneous nephrostomy
  • Avoid stone manipulation as it can lead to sepsis
33
Q

Prevention for recurrence of urinary stone disease

A
  • Sufficient fluid intake to consistently produce at least 2 litres of urine per day
  • Diet and lifestyle measures (eg: limit sodium intake, increase fruit and vegetable intake, weight loss)
  • Limit oxalate intake (eg: spinach, potatoes)
34
Q

4 contraindication of ESWL

A
  • Pregnancy
  • Febrile UTI
  • Coagulation defect uncorrected
  • Nearby vascular calcification or aneurysms
35
Q

Indication of nephrectomy

A
  • Renal cell carcinoma
  • Symptomatic hydronephrosis
  • Shrunken kidney
36
Q

Cause of initial, terminal and throughout hematuria

A
  • Initial: urethra cause
  • Terminal: near bladder neck or prostatic urethra
  • Throughout: bladder or upper urinary tract

Surgery (11 decks)

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