Lec 1 Urology Dr Ammar PDF

Urosurgery [Symptoms & Inv.] KIDNEY: They lie retroperitoneally on the posterior abdominal wall, one on each side of the vertebral column at the level of the T11-L3 vertebrates approximately 13cm in length, 7cm in width,...

Urosurgery [Symptoms & Inv.] KIDNEY: They lie retroperitoneally on the posterior abdominal wall, one on each side of the vertebral column at the level of the T11-L3 vertebrates approximately 13cm in length, 7cm in width, Type of epithelium, which is transitional epithelium to proximal The kidneys have the following covering urethra which converted to 1 !Perirenal fat squamous epithelium 2!Renal fascia: 3!Pararenal fat 1 Urosurgery [Symptoms & Inv.] Anatomy: Movement is limited so the kidney at risk of trauma especially in the paediatric KIDNEYS: The kidneys are supported by the perirenal fat (which is enclosed in the perirenal fascia), the renal vascular pedicle, abdominal muscle tone, and the general bulk of the abdominal viscera, (degree of renal mobility) Anteriorly: Posteriorly: The psoas Quadratus The adult kidney weighs about 150 g each. lumborum spleen Liver Relations of the kidneys. Transversus abdominis muscles. Pancreas Bowel Blood Supply: The renal artery divides into anterior and posterior branches. The posterior branch supplies the midsegment of the posterior surface. The anterior branch supplies both upper and lower poles as well as the entire anterior surface. The renal artery>>interlobar arteries>>arcuate>>interlobular arteries>>afferent. The renal veins are paired with the arteries The renal nerves derived from the renal plexus accompany the renal vessels The lymphatics of the kidney drain into the lumbar lymph Nodes The veins anastomose freely throughout the kidney, whereas the arterial supply does not. Anatomic variations in the renal vasculature are common in 25% to 40% of kidneys. 2 Urosurgery [Symptoms & Inv.] CALICES, RENAL PELVIS, AND URETER: ý Composed of 3 major calyces, each drains 3-5 minor calyces, joins together to form renal pelvis which is connected to the bladder by muscular tube called the ureter. ý Areas that stones are often impacted in the ureter are (1) at the ureteropelvic junction, (2) where the ureter crosses over the iliac vessels, and (3) where it courses through the bladder wall. ý Relation of lower ureter??? ý The renal calices, pelvis, and upper ureters derive their blood supply from the renal arteries; the mid ureter is fed by the internal spermatic (or ovarian) arteries. ý The lowermost portion of the ureter is served by branches from the common iliac, internal iliac (hypogastric), and vesical arteries. ý Lymph: upper>> lumber LN , Mid>> Int. iliac (hypogast) , lower>> vesical and hypogastric LN full ‫الزم‬catheter ‫ملن نحط‬ bladder of‫ علمود ماسوي‬rapture Detrusor BLADDER: peritoneum muscle Trigone ý Hollow muscular organ ý The adult bladder normally has a capacity of 400–500 mL ý Male Vs Female?? ý is largely a pelvic organ ý The ureters enter the bladder posteroinferiorly in an oblique manner and at these points are about 5 cm apart ý Internal structures?? ý Mucosa ý Blood , nerve & lymph supply PROSTATE GLAND; ý is a fibromuscular and glandular organ , weight 20 g ý It is supported anteriorly by the puboprostatic ligaments and inferiorly by the urogenital diaphragm ý Lowsley & McNeal classification ý Posteriorly, the prostate is separated from the rectum by the two layers of Denonvilliers’ fascia So the cancer doesn’t metastasis to the rectum ý Blood , nerve & lymph supply Hypogastric Pelvic splanchinc Internal and Inferior vesical nerve external iliac artery lymph node Usually prosthetic cancer in the peripheral zone and as symptomatic SEMINAL VESICLES; so the biopsy we take it by the rectum not by the urethra SPERMATIC CORD; Usually benign lesion of the prostate in the transitional zone and symptomatic so the biopsy we take it by urethra EPIDIDYMIS; When there is testicular cancer, we look for para aortic lymph node TESTIS; due to the relation of the test to the kidney When there malignancy of the scrotum we SCROTUM; blood & lymph Vs Testis look for inguinal lymph node PENIS AND URETHRA 3 The stone pain radiated to the genitalia  Urosurgery [Symptoms & Inv.] URINARY SYMPTOMS; Haematuria: > 3-5 RBC /HPF The presence of the clotting in the urine indicated of severe Heamaturia Important points about hematuria ; ý Macroscopical or microscopical? ý Initial, terminal or total? Painful heamaturia usually result ý Painless or painful. ? from stone or infection or benign lesion Painless heamaturia uasally cA ETIOLOGY I. Diseases of the urinary system—the most common cause Vascular arteriovenous malformation arterial emboli or thrombosis arteriovenous fistular nutcracker syndrome renal vein thrombosis loin-pain hematuria syndrome coagulation abnormality excessive anticoagulation 4 Urosurgery [Symptoms & Inv.] Glomerular IgA nephropathy , thin basement membrane disease (incl. Alport syndrome) Interstitial allergic interstitial nephritis , analgesic nephropathy , renal cystic diseases , acute pyelonephritis , tuberculosis , renal allograft rejection Uroepithelium malignancy vigorous excise trauma papillary necrosis cystitis/urethritis/prostatitis(usually caused by infection) parasitic diseases (e.g. schistosomiasis) nephrolithiasis or bladder calculi Multiple sites or source unknown hypercalciuria hyperuricosuria II. System disorders Hematological disorders plastic anemia leukemia , purpura , hemophilia ITP (idiopathy thrombocytopenic purpura) Infection infective endocarditis , septicemia , epidemic hemorrhagic fever , scarlet fever leptospirosis (leptospire) , filariasis (Wuchereria bancrofti ) Connective tissue diseases systemic lupus erythematosus (SLE) , polyarteritis nodosa Cardiovascular diseases hypertensive nephropathy , chronic heart failure , renal artery sclerosis Endocrine and metabolism diseases gout diabetes mellitus Diseases of adjacent organs to urinary tract Appendicitis, salpingitis carcinoma of the rectum carcinoma of the colon uterocervical cancer Drug and chemical agents sulfanilamides , anticoagulation cyclophosphamide , mannitol 5 Urosurgery [Symptoms & Inv.] miscellaneous exercise “idiopathic” hematuria DIFFERENTIAL DIAGNOSIS of Hematuria Polluted urine: menstruation Drugs : Rifampin (Rifadin) an antibiotic often used to treat tuberculosis, can turn urine reddish orange , also phenazopyridine (Pyridium) Food like Beets, blackberries Porphyria: porphyrin in urine (+) Hemoglobinuria Haemoglobinuria, there is no RBC in the microscope but there is haemoglobin in hemolysis dipstick test LABORATORY TESTS Three-glass test Method: collecting the three stages of urine of a patient during micturition Result: the initial specimen containing RBC—the urethra the last specimen containing RBC—the bladder neck and trigon area, prostatic urethra all the specimens containing RBC—upper urinary tract, bladder Phase-contrast microscopy to distinguish glomerular from post glomerular bleeding post glomerular bleeding: normal size and shape of RBC glomerular bleeding: dysmorphic RBC (acanthocyte) Hematuria with renal colic renal stone, ureter stone.. If with dysuria, micturition pause or staining to void: bladder or urethra stone Hematuria with urinary frequency,urgency and dysuria bladder or lower urinary tract (tuberculosis or tumor { bladder CIC}) if accompanied by high spiking fever, chill and loin pain: pyelonephritis Hematuria with edema and hypertension glomerulonephritis hypertensive nephropathy Hematuria with mass in the kidney neoplasm hereditary polycystic kidney Hematuria with hemorrhage in skin and mucosa hematological disorders infectious diseases Hematuria with chyluria Filariasis 6  Irritative symptoms indicated lower urethral issue so there is colicky pain and there is no urine if there is obstruction Urosurgery [Symptoms & Inv.] Renal Pain: Polycystic kidney disease Infection Pain is usually caused by acute distention of the renal capsule: inflammation, or obstruction.(what is the difference?) Pain of renal origin may be associated with gastrointestinal symptoms like nausea & vomiting. Ureteral Pain ( Ureteric Colic): Sudden severe agonizing pain, started at the loin, radiates to the ipsilateral iliac fossa, suprapubic region, and genitalia. The patient is rolling around?? Pain of the upper ureter radiated to the gastric and groin area The site of ureteral obstruction can often be determined by the location of the referred pain. Vesical Pain: overdistention of the bladder as a result of acute urinary retention or by Bladder inflammation (cystitis). Prostatic pain : Usually felt deep in the rectum, penis, pelvis perineum, suprapubic, low backache, & both iliac fossae. Urethral pain: usually at the tip of the penis but sometimes at its base, usually due to urethritis, cystitis or vesical or urethral calculus. ý Because the testicles arise embryologically in close proximity to the kidneys, pain arising in the kidneys or retroperitoneum may be referred to the testicles. Lower Urinary Tract Symptoms(LUTS) Irritative Symptoms; In the storage phase Frequency; increased urinary output (polyuria) or to decreased bladder capacity. Nocturia: Dysuria: Urgency: Indicated to the lower system was named Obstructive Symptoms: prostalism Weak stream. Urinary Hesitancy a delay in the starting (initiation) of micturition Intermittency (interrupted urinary stream). Postvoid dribbling Straining use of abdominal musculature to urinate. Feeling of Incomplete bladder evacuation. 7 Urosurgery [Symptoms & Inv.] ý Retention of urine: Inability to pass urine in spite of a full bladder bec.?? ý Anuria: complete absence of urine production. ý Oliguria is present when less than 300 ml of urine is excreted in a day ý Nocturnal Enuresis : Bed wetting (urinary incontinence that occurs during sleep ) Urethral Discharge v Pyuria: presence of pus in the urine. v Chyluria: presence of lymph in the urine. v Phosphaturia: presence of phosphate crystals in the urine. v Necroturia: presence of necrotic tissue in the urine as in malignancy. v Pneumaturia: presence of air in the urine. INVESTIGATION: I- URINALYSIS (General urine examination: GUE) physical, chemical, and microscopic analyses. Gravity , Color : yellowish Turbidity :phosphaturia , Pyuria Specific Gravity usually varies from 1.003 to 1.030. Osmolality is a measure of the amount of material dissolved in the urine and usually varies between 50 and 1200 mOsm/L. pH : between 5.5 and 6.5 Biochemical Examination of Urine: tested for with a dipstick include (1) Hemoglobin, (2) protein, (3) glucose, (4) ketones, (5) Electrolytes, (6) myoglobin , and (7) urobilinogen and bilirubin. 8 Urosurgery [Symptoms & Inv.] Parasites : Schistosoma ovum Bacteria Five bacteria/HPF reflects colony counts of about 100,000 bacteria/mL The finding of any bacteria in a properly collected midstream specimen from a male should be further evaluated with a urine culture Culture & sensetivity (C&S) of a clean-catch midstream specimen If there are pus cells in the urine but there is no growth>> sterile pyuria >> Early morning sample for AFB ( cultured on Lowenstein– Jensen medium to detect urinary tract tuberculosis) Analysis of a 24-hour specimen of urine: Cytology: poorly differentiated transitional cell tumours anywhere in the urinary tract. II- Renal function tests: More than 70% of kidney function must be lost before renal failure becomes evident. 1- Blood urea (Blood Urea Nitrogen)normally (15- 40 mg/dl) (2.5-6.5 mmol/l) It increases in dehydration, fasting, fever & after protein meal. Also in renal failure 2- Serum creatinine: (0.6-1.2 mg/dl) ( 62-124 μ mol/l) More accurate than urea and less affected by dehydration. 3- Creatinine clearance: (85-120 ml/min) give an approximate value for glomerular filtration rate. Needs 24h urine collection and a sample of blood. Cr. CL.= UV/P U : Cr. in urine (mg/dl) V: ml of urine excreted P: Cr. in plasma (mg/dl) III-URINARY TRACT IMAGING ULTRASONOGRAPHY: 9 Urosurgery [Symptoms & Inv.] X-Ray: KUB (kidneys, ureters, bladder): From lower chest to bellow the symph. Pubis. site, sex, stones, psoas shadow, skeleton, and soft tissue shadow. EXCRETORY UROGRAPHY (IVU , IVP, EXU ): Allows visualization of the entire urinary tract. The study provides demarcation of the renal parenchyma, the pelvicalyceal system, ureters, and bladder, providing both anatomic and functional information. Adverse Effects of Contrast Media - Idiopathic or anaphylactic reactions - Contrast media may induce an acute impairment of renal function - Diabetics managed with metformin (Glucophage) ;should have the drug withheld for 48 hours after receiving contrast material. C.I.: allergy, pregnancy, and renal impairment Retrograde ureteropyelography: Contrast medium injected through the catheter will demonstrate the anatomy of the upper urinary tract.. Antegrade pyelography: Antegrade pyelography – in which contrast medium is introduced through the nephrostomy – can be helpful when retrograde studies are prevented by obstruction at the extreme lower end of the ureter. 10 Urosurgery [Symptoms & Inv.] Cystography: Its role in assessing ureteric reflux in children, it provide information about the function and anatomy of bladder. Urethrography: Ascending urethrography is valuable to demonstrate the extent of a urethral stricture and the presence of false passages and diverticula associated with it. Arteriography is now rarely used to demonstrate tumour vasculature in a hypernephroma. COMPUTED TOMOGRAPHY ( CT scan) Non Contrasted (Native, non enhanced) Contrasted: Oral Contrast Agents Intravenous Contrast Agents ý CT scan accurately characterize the nature of tissue in the lesion. ý CT is useful in the preoperative evaluation and staging of tumors. ý CT has replaced IV urography as the primary modality for the assessment of suspected renal injuries and their complications ý For the evaluation of patients with acute flank pain, unenhanced spiral CT is more sensitive in detecting calculi than EXU. (except …………….?? stones). Drawbacks: Expensive, more radiation, not always available, need experience, contrast contraindications, pregnancy Magnetic resonance imaging and positron emission tomography: NUCLEAR IMAGING: The radionuclides currently available can measure perfusion, functional morphology (glomerular filtration and tubular secretion), excretion, and cortical morphology like cortical scar. Technetium Tc 99m Diethylenetriaminepenta-acetic Acid 99mTc-DTPA Technetium Tc 99m Mercaptoacetyltriglycine 99mTc-MAG3 Technetium Tc 99m Dimercaptosuccinic Acid 99mTc-DMSA Endoscopy: Direct visualization of the internal parts of the organ. Urethroscope, Cystoscope, Ureteroscope and Renoscope. Urodynamic studies: To study the function of the lower urinary tract( vesico-urethral unit). Include cystometry, flow rate, urethral pressure profile, video urodynamic studies, and EMG of pelvic floor. 11