ࡱ>   7bjbj-- 4^OO/d2<,&nnnnnIII%%%%%%%,'*%IIIII%nn%Ilnn%I%r$Tk%u8خ $%%0,&$zJ+J+k%k%$III%%III,&J+IIIIIIIII :    10-8-08 Kidney and Upper Urinary Tract Diseases Hematuria Hematuria presence of 3 or more RBCs per high-power-field in urine Dipstick a screening test only for hematuria (sensitive, not specific), needs microscopy confirmation Use hematuria is a starting point for clinical evaluation & differential Dx of GU disease Gross Hematuria more clinically significant finding than microscopic, further Dx: Initial gross hematuria implies source is urethra Terminal gross hematuria implies source is from bladder neck/prostate Total gross hematuria implies inferior to bladder, or upper urinary tract Red, but dipstick (-) consider dyes: phenolphthalein, rhodamine B, etc. Contamination if squamous cells present, means some skin rubbed off into urine cup ( need catheter Urine Examination for GU Disease Dipstick (+) but no RBCs may mean RBC lysis, or just false positive Pyuria/bacteruria means probable GU infection Proteinurea <2+ means probable glomerulonephritis Dysmorphic RBCs/ RBC casts GN Patient Hx for GU Disease Flank pain indicates a stone usually Dysuria, Bladder irritability indicates bladder/prostate infection Sickle cell anemia, diabetes risk factors for papillary necrosis Family History can pick up hereditary diseases (PKD, Alport, Nephronophtisis, calculi) Trauma/Intense Exercise can be cause of hematuria Tobacco Use, Chemical Exposure (dyes) risk factor for renal/urothelial cancers Patient Physical for GU Disease Blood Visible & Urethral Meatus hematuria has urethral source Fever, CVA Tenderness can be pyelonephritis Prostate Exam can find prostatitis, prostate cancer Pelvic Exam urethral, vaginal, labial lesions Labs/Procedures for GU Disease Urinalysis formal, 2/3 of patients w/ GU disease dont need this for accurate Dx Urine culture if infection, can omit rest of workup if hematuria clears with antibiotics Intravenous Urogram (IVU) strandard before KUB Kidney-Ureter-Bladder Radiograph (KUB) & Ultrasound traditional plain radiograph workup CT Scan best way recently to work up patients w/ hematuria Urine Cytology look for cells in urine suggesting cancer Serum Electrolytes/Creatinine assessment of renal function Cystoscopy only test done by surgical specialist, look for cysts in kidneys, last test after all others done Causes of Hematuria Infection bladder (cystitis), prostate (bacterial prostatitis), urethra (infectious urethritis) Calculi kidney (obstructive/non-obs; simple/staghorn); ureter; bladder Cancer renal cell ca., collecting system urothelial, urethral squamous cell, prostate adenoca. Benign neoplasms/lesions kidney (simple cysts, cystic renal disease, angiomyolipoma); uretric hemangioma; bladder endometrioma; urethral condyloma Other obstructions ureter (UPJ, intrinsic, extrinsic); bladder outlet (BOO, LUTS, BPH); urethral stricture Trauma/exertional do not assume Medical renal diseases nephritic syndrome etc. Blood dyscrasia/anticoag Benign familial hematuria microscopic only, all work-up comes back negative Ureteropelvic Junction Obstruction (UPJO) Typical Case 24 yo woman, Hx left flank pain (during fluid intake) Age typically diagnosed at young age, variable after childhood Symptoms an adult presentation has intermittent Sx, increased with fluids Intermittent symptoms typical adult presentation Pain on Fluid Intake classic finding for UPJO, flow-dependent obstruction Anatomy Review kidneys ( collecting tubules ( calyces ( infundibula ( renal pelvis ( ureter Obstruction Spots include ureteropelvic junction (UPJ), mid-ureter, ureterovesical junction Evalulation/Imaging can get IVU, renal scintigraphy, CT, US, Whitaker Intravenous Urogram see unilateral hydronephrosis (kidney large), shouldnt see ureter Diuretic Renal Scintigraphy nuclear medicine, may see renal function favoring one kidney Diuretic Renal Scinitigraphy is most definitive non-invasive obstruction test CT Scan another good imaging modality, can do 3D-reconstrution US quick & easy, real-time, but hard to see Doppler Resistive Indices assess kidney flow in sys/dias (obstruction = low dia. flow) Whitaker Test invasive test, most definitive ( catheter in kidney, see pressure change vs. flow Assessment is blockage complete/partial? Does kidney still function (worth repairing?) Treatment can give percutaneous endopyelotomy, nephro-ureteral stent Open pyeloplasty open surgery, cut open UPJO Percutaneous endopyelotomy UPJ is cut/dilated to relieve obstruction, reconstruct tissue Nephro-urethral stent between kidney & urethra, temporary & removed after healing UPJO Causes can be primary or secondary cause: Primary UPJO from excess muscle fibers, increased collagen, crossing of vessels, kinks, bands Secondary UPJO - from a traumatic or iatrogenic scar, internal compression (adjacent cancer) Urinary Tract Dilation can result from a UPJO, and can be caused by: Non-obstructive dilation ureteral reflux, prior obstruction (didnt revert), diuresis, stagnation Obstructive dilation increased resistance to urine flow ( increased pressure ( dilation Acutely Obstructing Renal Calculus Typical Case 30 yo man, sudden right flank pain, initial hematuria, afebrile, nausea, frequency, restless Symptoms sudden onset, frequent urination, hematuria ( Sx pass after stone moves on Nausea common If pain suddenly decreases, fornix ruptured ( probably a bad thing Pt. able to move ( not peritonitis Microscopic hematuria in 85% of renal calculus patients Acute Ureteral Obstruction Differential Dx includes calculi, clots, tumor, edema Extrinsic compression by tumor, node Acute vs. acute-on-chronic calculi or calculi hits stricture; is it a clot or a clot on a tumor? Evaluation/Imaging KUB & IVU get good anatomic picture, localize pathology; use contrast in IVU to make visualization easier US - quick & easy, real-time, but hard to see QUIZ: CT non-contrast most sensitive way to find calculus; also contrast CTs; contrast will light up Retrograde Pyelography inject nuclear tracer from urethra upwards Filling Defect Differential Dx neoplasm, blood clot (resolves), calculus (15% lucent, 85% opaque) Treatment can pass spontaneously Spontaneous passage 5mm stone has 50% chance of passing Drug Treatment aid in passage Non-Obstructing Renal Calculus Typical Case 65 yo man, microscopic hematuria, stone Hx, mild prostatism Evaluation/Imaging KUB plain radiography, can often visualize large stones IVU & US same deal CT same deal Surgical Treatment Indications infection, obstruction, pain, sepsis Urinary Tract infection need to Tx before leads to renal failure Significant obstruction urine backs up, could lead to renal failure Refractory Pain if drugs dont get rid of pain Staghorn Calculi risk of urosepsis if calculus gets much bigger Lifestyle reasons airline pilots Surgical Treatment Options Open/laparoscopic surgery most invasive, most effective (now rare b/c percuratneous is so effective w/ low morbidity); only for the largest stones Percutaneous nephrolithotomy from skin into kidney w/ cath, remove stone; largest stones Ureteroscopy scope up retrograde from ureter; moderate stones; distal ureter and middle ureter; denser stones (Ca oxalate monohyd), cystine Extracorporeal shock wave shock waves break up stone; smaller stones; proximal ureter and kidney; fuzzy/faint stones (dihyd, phosphate, sturvite), uric acid stones (these can also be alkalinized away) Pyelonephritis Typical Case 29 yo woman, 3 days dysuria, frequency, urgency; febrile, R flank pain, sexually active Prevalence most common kidney disease; in sexually active young women/men, often with UTI history Symptoms initial cystitis (ascends to kidneys), systemic (fever/chills), CVAT Afebrile usually bladder infection Febrile usually kidney infection Diagnosis usually thru findings above, and urine culture (bacteria, pyuria ( 85% GNR E. coli) Imaging not for initial diagnosis, but can be used to detect complications and predisposing factors: Complications papillary necrosis, pyonephrosis, abscess, sepsis Predisposing factors obstruction, calculi, vesico-ureteral reflex Lobar nephronia typical appearance on CT shows no distortion and highly localized decrease in blood flow due to edema Treatment give antibiotic Tx (oral in most, IV if very ill), should resolve in 2 days Lack of response to abx check for stone, obstruction Treat infection first then drain/remove stone In children US for scars and voiding cystogram to look for reflux Risk Groups diabetes, steroids, immunosuppressed, chronically ill Drainage indicated if there is an upper tract obstruction: Percutaneous Nephrostomy tube pass needle into site, thread in drainage catheter ( internal Ureteral Stent up ureter, stent passed up wire ( has part sticking out Renal Cell Carcinoma (RCC) Typical Case 64 yo man, gross hematuria, flank pain, smoking history, large painful R flank Prevalence common in old males (8th most common), 25% mortality rate Risk factors smoking, obesity, occupational, dialysis, von Hippel-Lindau disease, tuberous sclerosis Symptoms most commonly (but not frequently) hematuria, also flank pain & flank mass Pathology neoplasm of proximal tubule, often venous involvement (spreads even into IVC but can still be removed) Sequelae can have hemorrhage, necrosis, cyst, calcification; metastasis (lung, liver, bone, adrenal); angiogenesis factor mutations commonly associated (has led to specific treatments tgting angiogenic factors) Renal Tumors include RCC, urothelial cancer, oncocytoma RCC most common (85%), malignant Urothelial cancer less common, malignant Oncocytoma less common and looks just like RCC in imaging, benign Angiomyolipoma benign mass of proliferative vessels/fat cells, can bleed if large Histology have clear cell histology from lots of lipid cells, glycogen; grading 1-4 based on differentiation (1=well diff) Genetics most RCCs sporadic, but some related to syndromes: Von-Hippel Lindau Syndrome autosomal dominant, tumor in cerebellum/retina/adrenal/renal Cerebellar/retinal tumors were source of mortality before but now b/c of good surgical removal ( RCC Mutation in VHL tumor suppressor gene 3p25-26 causes 95% of cases ( gene therapy Paraneoplastic Syndrome Consequences elevated sedrate, thrombophlebitis, polycthemia or anemia, Ca++ elevation, hyperinsulin, LFTs hi Imaging Intravenous Urography typical imaging for hematuria, screening only ( find cyst/mass Ultrasound verifies simple cyst (benign) vs. solid mass (malignant), or indeterminate Simple cyst fluid-filled pocket, 85% of cases, benign, anechoic (post. enhancement) Solid mass malignant mass, less common, isoechoic (posterior is no different) Stone acoustic shadowing, sound cant penetrate (just like bone) CT current gold standard, conduct with/without contrast, can see masses MRI no advantage over CT except for: contrast allergy, high creatinine, vena cava spread Stage migration more imaging has led to earlier detection but now starting to see detection too early RCC Staging Stage I T1, less than 7 cm, limited to kidney ( radical/partial nephrectomy Stage II T2, greater than 7 cm, limited to kidney ( radical nephrectomy Stage III T3, N0/N1, in surrounding vein/fat/adrenals or 1 lymph node ( radical nephrectomy Stage IV T4, tumor beyond fascia, invading other organs ( systemic therapy (chemo/immuno) Radical Nephrectomy incision along ribs, make 25cm incision Prognosis Stage I/II good (80-90% 5 year survival), Stage III/IV bad ADPKD Autosomal Dominant Polycystic Kidney Disease hereditary disease, cysts in kidney Typical Case middle aged, full flanks from huge bilateral cysts, family Hx, HTN almost always (Review previous lecture) Cyst Evaluation Simple Cyst no further work-up needed, just let em go ADPKD definable by history & physical exam Acquired Cystic Kidney Disease (ACKD) definable by history & physical exam (often dialysis) Complex Cyst simple cyst complicated by infection/hemorrhage or cystic renal cancer (Dx dilemma) =FUd6 7 F U  + b u v w z    " 2 3 K W ` y ث؝hYTh9CJaJh^6h95CJaJhX6h956CJaJ jh^6h9CJaJh^6h9CJaJh9CJH*aJh/Vh9CJaJh9CJaJh95CJaJh{5CJaJjh|85CJUaJ32=F  b  3 y  ? 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