Surgical diseases of urinary tract Flashcards
What are some signs of urinary tract disease?
Stranguria, polyuria, anuria, dysuria
-vomiting
When is nuclear scintigraphy helpful in urinary cases?
If worried about GFR and kidney function
Where are the kidneys located?
In the retroperitoneal space
Which kidney is more mobile?
The left
What are the natural retractors for the kidney?
Mesocolon for left side
Mesoduodenum on right
Which renal artery is often paired?
The left
What size should you expect a kidney to be on radiographs?
2-2.5 times the length of adjacent vertebrae
What are some techniques for renal biopsy? why are these techniques being replaced by less invasive procedures?
Percutaneous, keyhole celiotomy, laparoscopic
- to preserve kidney function-often can damage kidney with these procedures
What are the indications for nephrotomy?
Wedge biopsy, chronic infections or hematuria, renal calculi, persistent hydronephrosis
Why is a pyelolithotomy preferred over a nephrotomy?
It causes no occlusion of the renal blood flow or damage to the renal parenchyma
What are some indications for nephrectomy?
Hydronephrosis (urolithiasis, stricture, mass, iatrogenic), renal neoplasia, renal cysts/abscesses, trauma (ruptured kidney, avulsion of renal artery), infection (dioctophyma renale aka kidney worm)
Describe the basic steps of a nephrectomy.
- Midline celiotomy
- retraction and visualization
- incise peritoneum and free kidney from sublumbar attachments, reflect medially to expose vessels (then isolate, triple ligate and divide)
Where should the ureters be cut during a nephrectomy?
Right at the bladder to prevent additional areas for UTIs
What type of suture should you use when placing encircling ligatures on renal vasculature?
Vicryl, silk, PDS
-can also use Thoracoabdominal stapling device
Which vessel should be ligated first- the artery or vein?
Whatever is easier- goal is to get out as soon as possible
What post op care and potential complications is important in nephrectomy cases?
Fluid therapy, analgesics
-hemorrhage and renal dysfunction of remaining kidney
If there is ureteral changes seen on a radiograph after contrast, what should you do?
REFER
- ureters are prone to leakage and stricture
-most common procedures done are neoureterocystotomy (for ectopic ureters), and ureterotomy (to remove calculi)
What are stents used for with urethral blockages?
Essentially bypasses the stricture- creates a new path
What is the subcutaneous renal bypass system?
Creating a new path for the urine to flow from kidney to bladder- creating “false” ureter
What is so special about the trigone region?
Needs to be preserved in surgery due to entrance of ureters, and is the area that initiates healing
What are the sources of blood supply for the bladder?
Cranial vesicular artery (branch of umbilical) and caudal vesicular artery (main one- branch of urogenital), internal pudendal veins
What nerves are the bladder innervated by?
Hypogastric provides sympathetic innervation, pelvic provides parasympathetic and pudendal exerts a somatic role (innervates external urethral sphincter)
What is the difference in appearance of stones and masses on ultrasound of the bladder?
Stones will be very hyperechoic and cast shadows, masses will have same opacity as the wall
What else can show up in the lumen of the bladder besides stones and masses?
Blood clots
What are the indications for cystotomy?
Removal of calculi, exploration of urinary bladder (biopsy and culture), neoplasia removal, repair of ectopic ureters, trauma
What are the steps to a cystotomy?
- Cut
- Explore completely (evert bladder, inspect mucosa)
- Biopsy/culture wall or stones
- Catheterize from both directions to be sure you can flush in both directions to be sure everything gets out
What is the holding layer of the bladder?
The submucosa
- be sure to avoid penetrating mucosa
How long does the bladder take to heal?
14-21 days
- mucosa re-epithelializes in 30 days
What should you always do after closure in cystotomy cases?
Post op radiographs
What should you do with stones removed?
Send out for culture
- important for post op antibiotic use and recommended diet
What are the indications for partial cystectomy?
Trauma, neoplasia
What is a perineal urethrostomy best for?
Repeat offenders
-failed medical management
