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X. MRCS: Anatomy > Urinary Tract > Flashcards

Urinary Tract Flashcards

1
Q

Kidneys: anatomical position

A

Retroperitoneal
Typically T12 - L3
Adrenal glands immediately superior

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2
Q

Kidneys: Layers

A 
Superficial to deep
Pararenal fat
Renal fascia (Gerota's fascia)
Perirenal fat
Renal capsule
Kidney
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3
Q

Kidney: parenchyma areas

A

Cortex (outer)

Medulla (inner)

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4
Q

Kidney: Organisation of parenchyma

A

Cortex extends into medulla, dividing it into triangular shapes: renal pyramids
Apex of perms is called renal papilla
Minor calyx collects urine from pyramids and merge to form major calyx.
Major calices drain into renal pelvis then into the ureter.

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5
Q

Kidney: arterial supply

A

Renal arteries (paired branches of aorta at L1, immediately distal to origin of SMA)
Right renal artery passes IVC posteriorly
Renal artery divides into anterior (75%) and posterior (25%) division. Supply 5 segmental arteries.
Segmental –>
interlobar arteries –>
Arcuate arteries –>
Interlobular arteries –>
Afferent arterioles –>
Glomerulus –>
Efferent arterioles
Peritubular network (supplies nephron)

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6
Q

Kidney: venous drainage

A

Left and right renal veins
Leave hilum anterior to renal artery
Drain into IVC
Left renal vein is anterior to abdominal aorta

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7
Q

Kidney: lymphatic drainage

A

Lateral aortic (para-aortic) lymph nodes

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8
Q

Ureters: anatomical course

A

Arise from renal pelvis at ureteropelvic junction
Descend through abdomen along anterior surface of posts major.
Retroperitoneal.
At SI joints, ureters cross pelvic brim entering pelvic cavity.
Cross bifurcation of common iliac.
Travel down pelvic wall at level of ischial spines. Turn anteromedially.
Pierce lateral aspect of bladder in oblique plane.

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9
Q

Ureters: blood supply

A

Abdominal: renal artery, testicular/ovarian artery, ureteral branches (direct of abdominal aorta)
Pelvic: superior and inferior vesical arteries

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10
Q

Ureters: venous drainage

A

Renal vein, testicular/ovarian vein, ureteral vein, superior and inferior vesical veins

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11
Q

Ureters: nerve supply

A

Renal, testicular/ovarian and hypogastric plexuses

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12
Q

Ureters: narrowest points

A

Uretopelvic junction
Pelvic brim
Entrance of ureter to bladder

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13
Q

Bladder: functions

A

Temporary storage of urine

Assists in expulsion of urine

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14
Q

Bladder: shape

A

Apex: superior
Body: between apex and fundus
Fundus (or base): posterior
Neck: convergence of fundus, continuous with urethra

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15
Q

Bladder: Blood supply

A

Superior vesical artery, branch if internal iliac
In males, supplemented by inferior vesical artery.
In females, vaginal artery.
Obturator and inferior gluteal may also contribute branches

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16
Q

Bladder: venous drainage

A

Vesical venous plexus. Empties into internal iliac vein.

In males, vesical plexus is in continuity at the retropubic space with prostate venous plexus (plexus of Santorini)

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17
Q

Bladder: lymphatic drainage

A

Superolateral: external iliac lymph nodes

Neck, fundus: internal iliac, sacral, common iliac nodes

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18
Q

Bladder: innervation

A

Sympathetic: hypogastric nerve (T12-L2). Causes relaxation of detrusor muscle, promoting urine retention
Parasympathetic: pelvic nerve (S2-S4). Causes contraction of detrusor muscle, stimulating micturation
Somatic: pudenal nerve (S2-4). External urethral sphincter giving voluntary control of micturation

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19
Q

Bladder: wall and musculature

A 
internal to external:
Transitional epithelium
Laminar propria
Submucosa
Detrusor muscle
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20
Q

Phases of micturition

A

Storage phase

Voiding phase

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21
Q

Storage phase of micturition

A 
Controlled by continence centres in pons which control continuance centres in spinal cord. 
Storage requires: relaxation of detrusor muscle, contraction of internal & external urethral sphincters
Sympathetic nuclei (T12-L2) --> hypogastric nerve --> detrusor & IUS
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22
Q

Voiding phase of micturition

A

Parasympathetic control
Afferent signals from bladder ascend to pontine micturition centre and cerebrum.
Upon voluntary decision to micturate, neurones of pontine micturition centre fire, exciting sacral preganglionic neurones.
Subsequent parasympathetic stimulation to pelvic nerve (S2-4) to muscarinic receptors on detrusor muscle, causing contraction.
Pontine micturition centre also inhibits Onuf’s nucleus reducing sympathetic simulation to IUS, causing relaxation.
Conscious reduction in voluntary contraction of EUS

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23
Q

Causes of urinary retention

A 
BPH
Nerve dysfunction
Infection
Constipation
Drugs (anticholinergics, antidepressants, opioids)
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24
Q

Urethra: parts

A

Prostatic urethra
Membranous urethra
Penile (bulbous) urethra

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25
Q

Prostatic urethra

A

Begins as continuation of bladder and neck
Passes through prostate gland
Receives ejaculatory ducts and prostatic ducts
Widest part of urethra

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26
Q

Membranous urethra

A

Passes through pelvic floor and deep perineal pouch
Surrounded by external urethral sphincter
Narrowest and least dilatable portion of urethra

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27
Q

Penile urethra

A

Passes through bulb and corpus spongiosum of penis
Ends at external urethral orifice (the meatus)
Receives bulbourethral glands proximally

28
Q

Urethra: blood supply

A

Prostatic: inferior vesical artery (branch of internal iliac)
Membranous: bulbourethral artery (branch of internal pudendal artery)
Penile: branches of internal pudendal artery

Female: internal pudendal artery

29
Q

Urethra: innervation

A

Prostatic plexus (mix of sympathetic, parasympathetic, visceral afferent)

Female: Pudenal nerve

30
Q

Urethra: Lymphatic drainage

A

Prostatic/mebranous: obturator and internal iliac nodes
Penile: deep and superficial inguinal nodes

Female: internal iliac nodes, superficial inguinal lymph nodes

31
Q

Zones of the prostate

A

McNeal’s zones
Central zone
Transitional zone
Peripheral zone

32
Q

Central zone of the prostate

A

Surrounds ejaculatory ducts
25% of normal prostate
Glands drain obliquely into urethra (relatively immune to urine reflux)

33
Q

Transitional zone of the prostate

A

Located centrally, surrounds the urethra
5-10% of normal prostate volume
Typically undergo BPH

34
Q

Peripheral zone of prostate

A

Main body of gland: 65%

Ducts vertically drain into urethra, allowing urine reflux

35
Q

Fibromuscular storm of prostate

A

Situated anterior to gland

Merges with tissue of urogenital diaphragm

36
Q

Blood supply to prostate

A

Prostatic arteries, branches of internal iliac

37
Q

Venous drainage of prostate gland

A

Prostatic venous plexus, draining into internal iliac veins

38
Q

Innervation to the prostate

A

Inferior hypogastric plexus

39
Q

Anatomical relations of the prostate

A

Neurovascular bundle to penis (can be damaged in prostatectomy)

40
Q

Kidney stones: composition

A 
Calcium oxalate (35%)
Calcium phosphate (10%)
Mixed oxalate/phosphate (35%)
Struvite (magnesium ammonium phosphate)
Urate (only radiolucent stones)
Cystine stones
41
Q

Struvite stones

A

Large soft stones
Commonest cause of “stag horn calculi”
Associated with UTI

42
Q

Pathophysiology of stone formation

A

Over-saturation of urine
Urate stones: high levels of purines (from red meat diet or myeloproliferative disorders)
Cystine stones: associated with homocystinuria

43
Q

Criteria for Inpatient management of stones

A

Post-obstructive AKI
Uncontrollable pain
Evidence of infected stones
Large stones >5mm

44
Q

Management of renal calculi

A 
Evidence of obstruction/infection: stent/nephrostomy
Small stones (<2mm): Extracorporeal shock wave lithotripsy (ESWL), CIs: pregnancy/near bony landmark
Large stones: Percutanous nephrolithotomy
45
Q

Bladder stones

A

Urine stasis. Commonly seen in chronic urine retainers.

Increases risk for SCC bladder.

46
Q

Renal cancer: types

A

Renal cell carcinoma (85%)
Transitional cell carcinoma
Nephroblastoma (Wilm’s tumour, paeds)
SCC (secondary to chronic inflammation, e.g. stones/UTI)

47
Q

Renal cell carcinoma, pathology, spread and RFs

A

Adenocarcinoma of renal cortex, predominantly from proximal tubule.
Most commonly in upper pole of kidney

Spread: local invasion (adrenal, renal vein, IVC), lymphatic (pre-aortic/hilar), haematogenous (bones, liver, brain, lung)

RFs: smoking. Industrial (cadmium, lead, aromatic hydrocarbons), dialysis, HTN, obesity, polycystic kidney, horseshoe kidney

48
Q

Renal cell carcinoma, clinical

A

Haematuria. Non-specific Sx. Flank mass. Left varicocele (compression of left testicular vein)
Paraneoplastic: polycythemia (EPO), hypercalcaemia (PTH), HTN (renin)
Sx of metastasis, 25% have mets at diagnosis

Ix: US for haematuria, CT with IV contrast.

49
Q

Renal cell carcinoma

A

Localised disease: Partial/radical nephrectomy

Metastatic disease: immunotherapy, biological agents (Sunitinib, Pazopanib: tyrosine kinase inhibitors)

50
Q

Bladder cancer: types

A

Transitional cell carcinoma (80-90%)
Squamous cell carcinoma
Adenocarcinoma
Sarcoma

51
Q

Bladder cancer: classifications

A

Non-muscle invasive bladder cancer
Muscle-invasive bladder cancer
Locally advanced
Metastatic

52
Q

Layers of the bladder wall

A 
Inner to outer:
Transitional epithelium (urothelium)
Lamina propria
Muscularis propria
Fatty connective tissue
53
Q

Bladder cancer: risk factors

A 
Smoking
Age
Aromatic hydrocarbons (industrial dyes/rubbers)
Schistosomiasis (SCC)
Radiation to pelvis
54
Q

Bladder cancer: investigations

A 
Haematuria:
BP
Bloods: U&Es, glucose, FBC, PSA,
>50: 2WW, CT urogram +/- contrast
<50 USS

Cystoscopy
Rigid cystoscopy & biopsy
CT staging (muscle invasive)

55
Q

Bladder cancer: management

A

NMI: resection via TURBT +/- adjuvant intravesical therapy (Bacille Calmette-Guerin). If high risk disease: radical cystectomy

MI: Radical cystectomy + urinary diversion (ill conduit/bladder recon), neoadjuvant chemo.

Locally advanced/metastatic: chemo

56
Q

Benign prostatic hyperplasia (BPH): risk factors

A

Age
FH
Black African/Caribbean ethnicity
Obesity

57
Q

BPH: clinical features

A

LUTS: voiding symptoms (hesitancy, weak stream, terminal dribbling, or incomplete emptying)
DRE: firm, smooth, symmetrical prostate

58
Q

BPH: medical management

A

a-adrenoreceptor antagonist (a-blocker): alfuzosin, doxazosin, tamsulosin or terazosin.
SEs: postural hypotension, retrograde ejaculation, floppy iris syndrome

5α-reductase inhibitors: Finasteride
SEs: can take 6months to have effect

Anti-cholinergic: Oxybutynin

59
Q

BPH: surgical management

A

If refractory to medical management or develop complications of BPH (high pressure retention)

(Minimally invasive)
TURP (complications: TURP syndrome, haemorrhage, sexual dysfunction, retrograde ejaculation, urethral stricture)

60
Q

TURP Syndrome

A

Hypoosmolar irrigation during procedure
Leads to fluid overload and dilution effect
Hyponatraemia
Sx: confusion, nausea, agitation, visual changes
Rx: Manage as hyponatraemia, replacing Na

61
Q

Prostate cancer: epidemiology

A

Most common cancer in men.
26% of male cancer diagnosis.
1 in 8 men will get prostate cancer in their lifetime.

62
Q

Prostate cancer: aetiology

A

Exact aetiology unknown.
Growth of cancer is influenced by androgens.
>95%: adenocarcinomas
75% from the peripheral zone. 20% transitional zone. 5% central zone. Often multifocal.
Acinar adenocarcinoma (most common) from glandular cells that line prostate.
Ductal adenocarcinoma from cells that line ducts: Grow and metastasise more rapidly

63
Q

Prostate cancer: clinical

A

LUTS. Haematuria, dysuria, incontinence, haematospermia. Suprapubic/loin pain.
Mets: bone pain, lethargy, anorexia.
DRE: asymmetrical nodularity, firm

64
Q

Prostate cancer: Investigations

A

PSA
MRI prostate
Targeted biopsy: transperineal, transrectal US guided
Gleason Grading System: most common growth pattern + second most common

65
Q

Prostate cancer: management

A

Low risk disease: active surveillance, radical treatments offered to those who show evidence of disease progression
Intermediate/high risk: radical prostatectomy
Metastatic: chemotherapy, anti-hormonal agents

Radical prostatectomy: open approach, laparoscopic, robot. SE: ED, incontinence, bladder neck stenosis

X. MRCS: Anatomy (18 decks)

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