Podcast
Questions and Answers
What is the management strategy for Grade 4 kidney injury with an infected urinoma?
What is the management strategy for Grade 4 kidney injury with an infected urinoma?
- DJ stent implantation
- Partial nephrectomy
- Pigtail catheter drainage (correct)
- Conservative management
Grade 1-3 kidney injuries require surgical intervention.
Grade 1-3 kidney injuries require surgical intervention.
False (B)
What feature is associated with Grade 5 kidney injuries?
What feature is associated with Grade 5 kidney injuries?
Expanding hematoma
Grade 5 kidney injuries may necessitate ________ for management.
Grade 5 kidney injuries may necessitate ________ for management.
Match the following grades of kidney injury with their corresponding management strategies:
Match the following grades of kidney injury with their corresponding management strategies:
Which zone of retroperitoneal trauma involves major vessels such as the aorta and IVC?
Which zone of retroperitoneal trauma involves major vessels such as the aorta and IVC?
A CT scan (CECT) is the preferred investigation for an unstable patient with renal injury.
A CT scan (CECT) is the preferred investigation for an unstable patient with renal injury.
What investigation is not useful in a stable patient with suspected renal injury?
What investigation is not useful in a stable patient with suspected renal injury?
A laceration less than 1 cm with no urinary extravasation is classified as a Grade ______ kidney injury.
A laceration less than 1 cm with no urinary extravasation is classified as a Grade ______ kidney injury.
Match the following renal injury grades with their descriptions:
Match the following renal injury grades with their descriptions:
Which of the following is NOT typically considered a clinical feature of urological issues?
Which of the following is NOT typically considered a clinical feature of urological issues?
The gold standard for confirming a urological infection is a urine culture.
The gold standard for confirming a urological infection is a urine culture.
What is the causative organism most commonly associated with pyelonephritis?
What is the causative organism most commonly associated with pyelonephritis?
In the management of a perinephric abscess, _____ therapy is administered a few weeks before any intervention.
In the management of a perinephric abscess, _____ therapy is administered a few weeks before any intervention.
Match the following terms with their respective descriptions:
Match the following terms with their respective descriptions:
What is an early finding in renal tuberculosis?
What is an early finding in renal tuberculosis?
A 'ghost calyx' refers to a normal calyx in healthy kidneys.
A 'ghost calyx' refers to a normal calyx in healthy kidneys.
What term describes the bladder capacity decrease due to renal tuberculosis?
What term describes the bladder capacity decrease due to renal tuberculosis?
In renal tuberculosis, the condition known as ______ affects the ureter due to the infection.
In renal tuberculosis, the condition known as ______ affects the ureter due to the infection.
Match the renal tuberculosis findings with their respective descriptions:
Match the renal tuberculosis findings with their respective descriptions:
Which of the following is NOT a complication of ureteric injury?
Which of the following is NOT a complication of ureteric injury?
Complete transection of the ureter with segment loss can be repaired using an anastomosis over a DJ stent.
Complete transection of the ureter with segment loss can be repaired using an anastomosis over a DJ stent.
Name one of the diagnosis methods used to identify ureteric injury.
Name one of the diagnosis methods used to identify ureteric injury.
A common complication after ureteric injury is the formation of a __________.
A common complication after ureteric injury is the formation of a __________.
Match the type of ureteric injury with its corresponding management:
Match the type of ureteric injury with its corresponding management:
What is the primary purpose of URS (Ureteroscopic Removal of Stones)?
What is the primary purpose of URS (Ureteroscopic Removal of Stones)?
What is the first line management for bladder stones?
What is the first line management for bladder stones?
PCNL is indicated for stones larger than 7 mm.
PCNL is indicated for stones larger than 7 mm.
Bladder stones can be caused by infection or obstruction.
Bladder stones can be caused by infection or obstruction.
What is one expected complication of PCNL?
What is one expected complication of PCNL?
The laser used in URS procedures is the _______-YAG laser.
The laser used in URS procedures is the _______-YAG laser.
Which type of stone is most commonly found in children with bladder stones?
Which type of stone is most commonly found in children with bladder stones?
Match the following procedures with their indications:
Match the following procedures with their indications:
Ureteric stones greater than ______ mm require ureteroscopic removal.
Ureteric stones greater than ______ mm require ureteroscopic removal.
Match the following conditions with their associated characteristics:
Match the following conditions with their associated characteristics:
What is the primary causative organism in emphysematous pyelonephritis?
What is the primary causative organism in emphysematous pyelonephritis?
Xanthogranulomatous pyelonephritis is more common in males than females.
Xanthogranulomatous pyelonephritis is more common in males than females.
What is the treatment approach for emphysematous pyelonephritis?
What is the treatment approach for emphysematous pyelonephritis?
A simple cyst is classified under Bosniak classification as Class _____ with a malignancy risk of _____%.
A simple cyst is classified under Bosniak classification as Class _____ with a malignancy risk of _____%.
Match the following Bosniak classes with their respective descriptions:
Match the following Bosniak classes with their respective descriptions:
Which of the following is a clinical feature of Vesico Ureteric Reflux (VUR)?
Which of the following is a clinical feature of Vesico Ureteric Reflux (VUR)?
Grade 3 VUR involves severe distention of the ureter along with loss of papillary impressions.
Grade 3 VUR involves severe distention of the ureter along with loss of papillary impressions.
What does MCU stand for in the context of VUR investigations?
What does MCU stand for in the context of VUR investigations?
In the management of Grade 1-3 VUR, _______ prophylaxis is recommended.
In the management of Grade 1-3 VUR, _______ prophylaxis is recommended.
Match the grades of VUR with their characteristics:
Match the grades of VUR with their characteristics:
What is the primary origin of angiomyolipoma?
What is the primary origin of angiomyolipoma?
Oncocytoma is the most common benign renal tumor.
Oncocytoma is the most common benign renal tumor.
What is the management for symptomatic angiomyolipoma larger than 4 cm?
What is the management for symptomatic angiomyolipoma larger than 4 cm?
The clinical feature known as __________ syndrome is associated with spontaneous retroperitoneal hemorrhage in angiomyolipoma.
The clinical feature known as __________ syndrome is associated with spontaneous retroperitoneal hemorrhage in angiomyolipoma.
Match the following terms related to benign tumors with their descriptions:
Match the following terms related to benign tumors with their descriptions:
Study Notes
Kidney Injury Grades
- Grade 1-3: Conservative management
- Grade 4:
- Sterile: DJ stent implantation
- Infected: Pigtail catheter drainage
- Urinoma: Requires specific management
- Grade 5: Partial/total nephrectomy
Features of Kidney Injury
- Grade 4: Specific features not detailed
- Grade 5:
- Expanding hematoma
- Pulsatile leak
- Non-visualization on IVU
Management Strategies
- Exploration and repair of Grade 4 and 5 injuries may be required
Retroperitoneal Trauma Zones
- Zone 1: Major vessels (aorta, IVC, pancreas) - high mortality
- Zone 2: Kidney, ureter, and renal vessels
- Zone 3: Pelvic structures - most common involvement
Renal Injury Investigations
- Stable patient: CT scan (CECT)
- Unstable patient: Intravenous urogram (IVU)
- IVU: Dye injection (urograffin)
Renal Injury Grading on Diagram
- Grade 1: Laceration less than 1 cm, no urinary extravasation
Urology - Notes
- Clinical Features:
- Hematuria
- Pain
- Mass
- Weight Loss
- Investigations:
- IOC: CT urography
- Urine Routine microscopy: Pus cells (+) Sterile pyuria
- Urine Culture & sensitivity: Sterile
- Gold standard: TB culture
- Management:
- Perinephric abscess: ATT (Anti tubercular therapy) before intervention (exception: early drainage followed by ATT)
- Surgical intervention:
- Perinephric abscess: Pigtail catheter
- Kinking of ureter: DJ stenting
- Golf hole ureteric orifice: Reimplantation of ureter
- Thimble bladder: Augmentation cystoplasty (using ileum)
Pyelonephritis
- Clinical features:
- Pain
- Fever
- Risk factors:
- Females > males
- Pregnancy
- Pathogenesis:
- Causative organism: Most common - E. coli
- Mechanisms:
- Hematogenous
- Ascending infection (VUR)
Renal Tuberculosis
- Secondary infection via hematogenous route
- Pathogenesis:
- Multiple ulcers → Caseous necrosis → Pus filled → Calcification
- Other possible findings:
- Papillary ulcer (earliest)
- Perinephric abscess:
- Ghost calyx
- Putty kidney
- Cement kidney
- Kerr's kink of ureteropelvic junction
- Golf hole ureteric orifice:
- Stricture (remains open)
- Shortening of ureter
- Thimble bladder: ↓ capacity
- Cortical abscess with rupture into the perinephric space
- Ureteral stricture
- Thickened bladder wall (tumble bladder)
- Urethral stricture
- Beaded ureter
- Moth-eaten calyx (ghost calyx)
- Testis + Epididymis → Epididymo-orchitis:
- Beading of vas
- Sinus formation
- Prostate: Boggy
Ureteric Injury
- Complications:
- Hematuria
- Urinomas
- AV fistula
- Renal artery thrombosis (Renal infarct)
- Meteorism (Colonic distension 48-72 hours after renal injury d/t pressure over splanchnic nerves)
- HTN (resistant to antihypertensives)
Ureteric Injury Causes
- Surgery
- Hysterectomy
- Pelvic tumor resection
Ureteric Injury Management & Outcomes
- Partial injury: Repair with absorbable suture
- Complete Tear (without segment loss): Anastomose over DJ stent
- Complete Transection (with segment loss): Boari Flap repair, Psoas hitch
Ureteric Injury Realized After Surgery
- Presentations:
- Urinomas (Pigtail catheter → DJ stent)
- Renal atrophy (d/t complete ureteric tie off)
- Fistula (most common: uretero-vaginal fistula)
- Diagnosis:
- CT urography
- IVU
- Treatment: Repair
Kidney Procedures
- URS (Ureteroscopic Removal of Stones):
- Visualize and remove stones via ureter
- Laser: Holmium-YAG
- PCNL (Percutaneous Nephrolithotomy):
- Indications:
- Stones > 7 mm
- Lower pole stones, unfavorable for SWL (Shockwave Lithotripsy)
- Failed ESWL/RIRS (Extracorporeal Shockwave Lithotripsy/Retrograde Intrarenal Surgery)
- Staghorn calculi
- Hydronephrotic kidney
- Mini PCNL: < 22 Fr tract in children and patients with smaller disease burden
- Complications:
- Bruising
- Hematuria
- Indications:
Ureteric Stones
- IOC: NCCT
- Differential Diagnosis:
- Gall Bladder stone (on lateral X-ray: Anterior)
- Pills
- Foreign body
- Calcified 12th rib
- Management:
-
5mm: ureteroscopic removal/Dormia basket
-
Bladder Stones
- Types:
- Primary:
- Formed in sterile urine
- Usually in children
- Most common: mixed urate stones
- Secondary:
- 2° to infection/obstruction
- Adults
- Calcium oxalate (Jack stones)
- Primary:
- Presentation:
- Hematuria
- Pain
- IOC: NCCT
- Management:
- 1st Line: Perurethral Cystolithotomy
- Contraindications:
- Urethral stricture
- Bladder diverticula
- Alternative Management: Suprapubic cystolithotomy
Vesico Ureteric Reflux (VUR)
- Upward flow of urine on micturition
- Clinical Features:
- Recurrent UTI
- Pyelonephritis
- Renal scarring → ↓ renal function
- Investigation:
- 10C: MCU (Mictrurating cystourethrogram)
- Grading:
- Grade 1: Reflux into non dilated ureter
- Grade 2: Reflux into pelvis but no distention
- Grade 3: Reflux with mild distention
- Grade 4: Blunting of calyces/tortuous ureter
- Grade 5: Severe distention of ureter along with loss of papillary impressions
- Management
- Grade 1-3: Antibiotic prophylaxis
- Grade 4-5: Antibiotic prophylaxis + intervention:
- Endoscopic:
- STING (Subureteric Teflon Injection)
- Alternative: Deflux
- Open Sx: Reimplantation of ureters:
- Politano - Leadbetter technique
- Endoscopic:
- HIT: Hydrodistension implantation technique
Kidney: Part 2
- Investigations:
- Urine: WBC cast
- Urine culture & sensitivity
- CECT: IOC
- Types of pyelonephritis:
- Emphysematous pyelonephritis:
- Causative organism: E. coli
- Associated with immunocompromised state, DM
- Presentation: Fever, flank pain close to renal angle
- IOC: CECT → Gas around kidney
- Mx: IV antibiotics + Drainage via pigtail catheter. Failure → Nephrectomy
- Xanthogranulomatous pyelonephritis:
- Causative organism: Proteus > E. coli
- Seen in middle-aged females
- Associated with DM
- Presentation: Flank pain, pyrexia, abdominal mass, calculi
- IOC: CECT → Non-functional kidney, low density mass, staghorn calculi
- Mx: Antibiotics + Subcapsular nephrectomy
- Emphysematous pyelonephritis:
- Treatment:
- IV antibiotics x 7-10 days
- If pus → Drain
Renal Tumors
- IOC: CECT
Bosniak Classification
- Class 1: Simple cyst - Nil workup - 0% malignant
- Class 2: Minimally complex - Nil workup - 0% malignant
- Class 2F: Minimally complex (Need follow up) - USG or CT follow-up - 5% malignant
- Class 3: Indeterminate - Partial nephrectomy - 50% malignant
- Class 4: Clearly malignant - Partial/Total nephrectomy - 100% malignant
Benign Tumors
1. Angiomyolipoma
- Tumor of blood vessel, muscle, and fat
- Origin: Perivascular epithelioid cells (PEC)
- Age of onset: 5th-6th decade of life
- Associated with: Tuberous sclerosis (2nd-3rd decade of life, multiple bilateral lesions, dermatological lesions, Ash leaf macules, Shagreen patches, Adenoma sebaceum, and familial syndrome)
- Clinical Features:
- Asymptomatic
- Pain
- Lump
- Wunderlich syndrome (Spontaneous retroperitoneal hemorrhage, Lenk triad: No hematuria, Hypotension, Pain)
- Investigations:
- IOC: CECT
- B/L lesions: Bosniak 3
- Management:
- 4 cm & symptomatic: Partial nephrectomy/Nephron sparing surgery followed by partial nephrectomy
- Bleeding angiomyolipoma: Angioembolisation
2. Oncocytoma
- Most common benign renal tumor
- Origin: Cells rich in mitochondria
- Cytoplasm: Eosinophilic
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Description
Test your knowledge on the grading of kidney injuries, their management strategies, and the clinical features associated with each grade. This quiz covers topics from investigation techniques to trauma zones, providing a comprehensive overview of renal injury management in urology.
