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Questions and Answers
What is the primary site of kidney development?
What is the primary site of kidney development?
The left renal vein is shorter than the right renal vein.
The left renal vein is shorter than the right renal vein.
False
What syndromes are associated with compression of the left renal vein between the SMA and aorta?
What syndromes are associated with compression of the left renal vein between the SMA and aorta?
Nutcracker syndrome and renal cell carcinoma
The renal vein splits to encase the ______.
The renal vein splits to encase the ______.
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Match the following structures with their positions at the kidney hilum:
Match the following structures with their positions at the kidney hilum:
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What is the first line intervention for kidney stones when medical therapy fails?
What is the first line intervention for kidney stones when medical therapy fails?
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Uncontrolled bleeding disorders are a contraindication for using ESWL.
Uncontrolled bleeding disorders are a contraindication for using ESWL.
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List one symptom that indicates the need for medical expulsive therapy in kidney stones.
List one symptom that indicates the need for medical expulsive therapy in kidney stones.
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ESWL uses ______ dynamics to treat kidney stones.
ESWL uses ______ dynamics to treat kidney stones.
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Match the indications with the appropriate surgical procedure:
Match the indications with the appropriate surgical procedure:
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Which gender-specific anomaly is associated with renal agenesis in males?
Which gender-specific anomaly is associated with renal agenesis in males?
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The Weigert-Meyer Rule states that the ureter draining the upper pole inserts medially in the bladder.
The Weigert-Meyer Rule states that the ureter draining the upper pole inserts medially in the bladder.
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What is the typical presentation for a female with duplication of the ureteric system?
What is the typical presentation for a female with duplication of the ureteric system?
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In males, the ectopic location of the ureter may open into the ______.
In males, the ectopic location of the ureter may open into the ______.
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Match the following terms with their descriptions:
Match the following terms with their descriptions:
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Which of the following is the best option for assessing kidney function?
Which of the following is the best option for assessing kidney function?
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Benign prostatic hyperplasia (BPH) can cause unilateral issues in the kidneys.
Benign prostatic hyperplasia (BPH) can cause unilateral issues in the kidneys.
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What do you measure to evaluate the functioning of the kidneys using DMSA?
What do you measure to evaluate the functioning of the kidneys using DMSA?
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A DJ stent is used to maintain the __________ of the ureters.
A DJ stent is used to maintain the __________ of the ureters.
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Match the following conditions with their related urinary issues:
Match the following conditions with their related urinary issues:
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What is the common shape of uric acid stones?
What is the common shape of uric acid stones?
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Strangury is characterized by the passing of large quantities of urine.
Strangury is characterized by the passing of large quantities of urine.
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What imaging technique is considered the investigation of choice (IOC) for kidney stones?
What imaging technique is considered the investigation of choice (IOC) for kidney stones?
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Uric acid stones are associated with conditions such as ______ and ______.
Uric acid stones are associated with conditions such as ______ and ______.
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Match the type of kidney stones with their descriptions:
Match the type of kidney stones with their descriptions:
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Which type of polycystic kidney disease is considered incompatible with life?
Which type of polycystic kidney disease is considered incompatible with life?
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Hypertension is the most common clinical feature in young patients with adult polycystic kidney disease.
Hypertension is the most common clinical feature in young patients with adult polycystic kidney disease.
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What genetic location is associated with adult polycystic kidney disease?
What genetic location is associated with adult polycystic kidney disease?
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The __________ sign indicates duplication with malrotation of the pelvis.
The __________ sign indicates duplication with malrotation of the pelvis.
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Match the following extra-renal manifestations with their conditions:
Match the following extra-renal manifestations with their conditions:
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What is the most common acquired cause of unilateral hydronephrosis?
What is the most common acquired cause of unilateral hydronephrosis?
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Clubbing of calyces is a result of normal urine flow.
Clubbing of calyces is a result of normal urine flow.
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What is the term used for the surgical procedure that relieves obstruction in hydronephrosis?
What is the term used for the surgical procedure that relieves obstruction in hydronephrosis?
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In hydronephrosis, the most common congenital cause is __________.
In hydronephrosis, the most common congenital cause is __________.
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Match the investigation technique with the condition it is used for:
Match the investigation technique with the condition it is used for:
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What is the characteristic presentation of multicystic dysplastic kidney at birth?
What is the characteristic presentation of multicystic dysplastic kidney at birth?
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A horseshoe kidney typically ascends freely without restrictions.
A horseshoe kidney typically ascends freely without restrictions.
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What imaging technique is primarily used to investigate horseshoe kidney?
What imaging technique is primarily used to investigate horseshoe kidney?
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The presence of multiple cysts in the kidney is commonly detected using __________ imaging.
The presence of multiple cysts in the kidney is commonly detected using __________ imaging.
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Match the following conditions with their descriptions:
Match the following conditions with their descriptions:
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Which type of renal stone is most common?
Which type of renal stone is most common?
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Triple Phosphate Stones are formed in acidic urine.
Triple Phosphate Stones are formed in acidic urine.
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What dietary advice is recommended for patients with recurrent Calcium Oxalate Stones?
What dietary advice is recommended for patients with recurrent Calcium Oxalate Stones?
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Cystine Stones are often associated with the condition known as _____ .
Cystine Stones are often associated with the condition known as _____ .
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Match the types of renal stones with their characteristics:
Match the types of renal stones with their characteristics:
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Which investigative method shows the 'Cobra Head' sign indicative of ureterocele?
Which investigative method shows the 'Cobra Head' sign indicative of ureterocele?
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Retroperitoneal fibrosis can be idiopathic or drug-induced.
Retroperitoneal fibrosis can be idiopathic or drug-induced.
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What surgical procedure is typically utilized for managing aberrant renal vessels?
What surgical procedure is typically utilized for managing aberrant renal vessels?
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In severe cases of retroperitoneal fibrosis, management may necessitate the placement of a __________.
In severe cases of retroperitoneal fibrosis, management may necessitate the placement of a __________.
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Match the following conditions with their associated clinical features:
Match the following conditions with their associated clinical features:
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Study Notes
Management of Kidney Stones
- Medical expulsive therapy is a first line treatment for symptomatic stones less than 6mm in diameter.
- Tamsulosin is a useful alpha-blocker for difficult to pass stones.
- ESWL (Extracorporeal Shock Wave Lithotripsy) is a first line intervention for failed medical expulsive therapy.
- ESWL uses ultrasonic waves to break up kidney stones.
- Pain, urinary tract infection (UTI), and hematuria are common complications of ESWL.
- ESWL is contraindicated in pregnancy, uncontrolled bleeding disorders, cardiac pacemaker patients, stones larger than 1.5 cm, obesity, children, musculoskeletal deformities, very hard stones, and an obstructed urinary system.
- RIRS (Retrograde Intra-renal Surgery) is an alternative to ESWL for stones less than 2 cm, particularly those in the lower pole of the kidney.
Surgical Anatomy of the Kidney
- The kidney develops from metanephric buds in the iliac fossa and ascends to the lumbar region.
- The left renal vein is longer than the right, which makes it a preferred donor kidney but also prone to secondary varicocele.
- Left testicular vein obstruction, due to its longer length, can cause varicocele.
- Renal cell carcinoma is often associated with the left renal vein, which is compressed between the superior mesenteric artery and aorta.
- Nutcracker syndrome, caused by compression of the left renal vein between the SMA and aorta, can cause hematuria and flank pain.
- The renal vein splits to encase the aorta, forming the renal collar on the left side.
- The renal pelvis is located posterior to the renal artery, which sits in the middle, and the renal vein is located anteriorly in relation to the hilum.
Congenital Kidney Disorders
- Renal agenesis is the absence of a kidney, often accompanied by agenesis of the ureter, hemitrigone, undescended testes (males), absent fallopian tubes (females), and absence of the adrenal gland.
- Duplication of the ureteric system can occur with the upper pole ureter inserting distally and medially in an ectopic location, typically the urethra in males or vagina in females.
- The lower pole ureter typically inserts in a normal location in cases of duplication.
- Ectopic insertion of the upper pole ureter can present with symptoms like recurrent UTI in males or constant wetting in females, but with normal urinary control from the lower pole ureter.
- Retrocaval ureter is a rare condition where the right ureter lies behind the IVC and can be identified by the fish hook or reverse J sign on imaging.
- Bilateral retrocaval ureter can be caused by various conditions, including benign prostatic hyperplasia, bladder outlet obstruction, posterior urethral valves, phimosis, and meatal stenosis.
Kidney Assessment Notes
- Renal isotopes scans are a key tool for assessing kidney function and structure.
- Technetium 99m DMSA (Dimercapto succinic acid) is used to assess structural anomalies and scarring.
- DTPA and MAG 3 are used to assess overall kidney function, with MAG 3 being considered the best option.
- IVU (Intravenous Urogram) is used to assess for hydronephrosis.
Kidney Stones
- Calcium oxalate stones are the most common type of kidney stone, found in acidic urine.
- Calcium oxalate stones can be monohydrate (dumbbell shaped), dihydrate (envelope shaped), or spiculated (mulberry stones).
- They can present early with pain and hematuria.
- Dietary advice for recurrent calcium oxalate stones includes reducing fat intake and increasing calcium intake.
- Triple phosphate stones, also known as struvite or staghorn stones, are formed in alkaline urine, often infected with Proteus.
- These stones have a coffin lid shape and grow in size until reaching the calyx, eventually taking on its shape.
- They are radiopaque.
- Cystine stones are rare, radiopaque, very hard, hexagonal, crystalline lattice stones.
- They are difficult to break with ESWL and are often associated with cystinuria.
- Recurrent cystine stones are treated with d-Penicillamine.
- Uric acid stones are radiolucent, with a crystal shape resembling glass shards.
- They are often associated with tumor lysis syndrome, gout, and a mixture of recurrent stones.
- Allopurinol is a common medication to treat uric acid stone formation.
- Indinavir and triamterene are rare types of radiolucent kidney stones.
- Kidney stones are often associated with pain, which can be localized, colicky, or strangury.
Hydronephrosis
- Hydronephrosis refers to the dilation of the pelvi-calyceal system caused by intermittent partial or complete urinary flow blockade.
- This condition can be caused by a variety of factors, both congenital and acquired.
- Intraluminal causes are more commonly acquired and include kidney stones and sloughed papilla, often seen in diabetes mellitus or analgesic abuse.
- Intramural causes are most commonly congenital and include pelvic ureteric junction (PUJ) obstruction.
Polycystic Kidney Disease
- Polycystic kidney disease (PKD) is characterized by multiple cysts that enlarge and press on the normal renal parenchyma.
- There are two main types: infantile PCKD and adult PCKD.
- Infantile PCKD is autosomal recessive, not compatible with life, and results in death due to hepatic fibrosis.
- Adult PCKD is autosomal dominant and compatible with life.
- The gene location for infantile PCKD is PKHD on chromosome 6, while for adult PCKD it is PKD 1 on chromosome 16 or PKD 2 on chromosome 4.
- Adult PCKD typically presents in late 20s to early 30s and can manifest with hypertension, pain, hematuria, and renal failure.
- Extrarenal manifestations include cysts in the liver, spleen, pancreas, and lungs, colonic diverticulosis, and mitral valve prolapse.
- Polycystic kidney disease is a common cause of hypertension in young patients, along with renal artery stenosis, pheochromocytoma, hyperthyroidism, and berry aneurysms in the circle of Willis.
Management of Hydronephrosis
- Hydronephrosis and malrotated pelvis are managed with pyeloplasty, a procedure to relieve the urinary tract obstruction.
- Due to the risk of devascularizing both kidneys, the fused portion in a horseshoe kidney should never be cut, except in cases of symptomatic abdominal aortic aneurysm.
Urology
- A ureterocele, a cystic dilation of the distal ureter, can present with recurrent UTI and decreased renal function.
- Investigation of a ureterocele is done with IVU which shows the “cobra head or adder head” sign.
- Ultrasound examination of a ureterocele shows dilated terminal ends.
- Management involves endoscopic procedures to ensure drainage and excision or reimplantation of the ureter.
Extra Luminal Causes of Hydronephrosis
- Aberrant renal vessels, which are vessels in the wrong location, can lead to hydronephrosis, and are managed with pyeloplasty, in most cases, without cutting the aberrant vessels.
- Advanced cancers, such as soft tissue sarcomas, cervical, prostatic, and colonic cancers, can compress the ureter, causing hydronephrosis.
- Management involves treating the cancer.
- Retroperitoneal fibrosis, also known as Ormond’s disease, is a fibrotic condition that can lead to hydronephrosis due to compression of the ureter.
- The cause is often unknown, but some cases are drug-induced, IgG-mediated, or related to Dupuytren's contracture or Peyronie's disease.
- Management involves identifying the cause, if possible, and includes radiotherapy and, in severe cases, a DJ (double J) stent.
- The “maiden waist deformity” seen on IVU can be a sign of retroperitoneal fibrosis.
Multi-cystic Dysplastic Kidney
- Multi-cystic dysplastic kidney (MCDK) is characterized by multiple unilateral or bilateral cysts.
- Bilateral MCDK is not compatible with life.
- Presentation is often an abdominal lump at birth, with rapid progression to renal failure in adults.
Horseshoe Kidney
- Horseshoe kidney is a congenital condition where the lower ends of the kidneys are fused.
- The fused portion lies at L3-L4, with the kidneys ascending no further due to the inferior mesenteric artery (IMA).
- The adrenal glands are normally positioned.
- Most patients are asymptomatic and only present with a lump or hydronephrosis.
- IVU can show the “flower vase or hand shake” sign in the horseshoe kidney.
- Horseshoe kidneys are susceptible to renal calculi and infections.
Investigations for Urological Conditions
- USG (ultrasound) is an effective tool for identification of multiple cysts within the kidney.
- Pre-natal scans can identify polycystic kidney disease if there are ≥ 3 cysts (unilateral or bilateral) or ≥2 cysts in both kidneys.
Treatment of Polycystic Kidney Disease
- Treatments for polycystic kidney disease include drugs like vasopressin receptor antagonists and mTOR inhibitors.
PJ Obstruction
- Pelvi-ureteric junction (PUJ) obstruction describes a blockage in the place where the pelvis of the kidney meets the ureter.
- Symptoms of PUJ obstruction can include recurrent UTIs and decreased renal function.
- The “cobra head or adder head” sign on IVU can be a sign of PJ obstruction.
- Ultrasound of PUJ obstruction can show dilated terminal ends of the urinary tract.
- Anderson-Hynes pyeloplasty is a surgical procedure to correct PUJ obstruction.
- If a patient presents with a transitional cell cancer (TCC) of the pelvis, the “goblet sign” on IVU can be seen.
Urology Notes
- For recurrent kidney stones, dietary modifications can include reducing dietary oxalate intake and increasing fluids.
- ESWL is a common treatment method but is often not effective for all types of kidney stones.
- Kidney stones can significantly impact the quality of life and might require additional investigation and treatment.
- Kidney stones can present with various complications that need to be identified and managed.
Additional Notes
- The provided information is a summary of the text, and may not fully represent the complexity of kidney disorders and their related treatments.
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Description
This quiz covers key aspects of kidney stone management, including medical expulsive therapy, ESWL, and RIRS interventions. It also touches on potential complications and contraindications for treatment methods. Test your understanding of recent guidelines and anatomical considerations in treating kidney stones.
