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- 1. O B ST R U C T I V E U R O P A T H Y & U R I N A R Y T R A C T C A L C U L I A S Y I Q I N U W A I S
- 2. Anatomy of urinarysystem Kidneys Ă Excrete the end products of metabolism and excess water Ă Endocrine functions: Ă Producing and releasing erythropoietin which affects red blood cell formation, renin which influences blood pressure, Ă 1,25-hydroxycholecalciferol, which is involved in the control of calcium metabolism Ureter Ă A muscular tube that conveys urine from kidneys to urinary bladder Bladder Ă A reservoir that store and excrete urine
- 3. Anatomy of kidney Location ĂRetroperitoneal Ă Lies in each side of vertebral column, T12 â L3 level Ă The left kidney is slightly higher than the right kidney by half an inch. Shape Ă the kidney is bean- shaped organ and has 2 Poles, 2 borders and 2 surfaces. Measurement Ă Length : 10 -12 cm Ă Breadth : 5 â 7.5 cm Ă Thickness: >2.5 cm Ă Weight: Ă Male: 125 â170 gm Ă Female: 115â150 gm Ă Kidney: Body weight: (1:240) The parenchyma of each kidney usually drains into seven calyces, three upper, two middle and two lower calyces.
- 4. Covering of thekidney 1. Kidney 2. Renal capsule (tough fibrous tissue) 3. Perinephric fat (collection of extraperitoneal fat) 4. Renal fascia (Encloses the kidneys and the suprarenal glands also known as Gerotaâs fascia or perirenal fascia) 5. Paranephric fat (mainly located on the posterolateral aspect of the kidney)
- 5. Relations of kidney ANTERIORPOSTERIOR Ă Faces anterolateral Ă Covered with peritoneum. Ă Faces posteromedial Ă No peritoneal covering.
- 6. Anatomy of ureter Theureters are muscular ducts (25-30 cm long) with narrow lumina that carry urine from the kidneys to the urinary bladder Run inferiorly from the apices of the renal pelvis at the hila of the kidneys Courses Passing over the pelvic brim at the bifurcation of the common iliac arteries. Run along the lateral wall of the pelvis and enter the urinary bladder Sites of constrictions Junction of pelvis and ureter Crossing of pelvic brim Entrance of urinary bladder
- 7. Major relations Rightureter: Psoas major muscle, genitofemoral nerve, duodenum (descending part), branches of the superior mesenteric vessels, gonadal vessels, common iliac artery, uterine artery, urinary bladder Left ureter: psoas major, genitofemoral nerve, branches of the inferior mesenteric vessels, gonadal vessels, common iliac artery, uterine artery, urinary bladder Blood supply Ureteric branches of renal artery, ovarian/testicular artery, ureteric branches of the abdominal aorta and common iliac arteries, ureteric branches of the superior and inferior vesical and uterine arteries Innervation Renal plexus and ganglia, aortic plexus, ureteric branches of intermesenteric plexus, pelvic splanchnic nerves, superior and inferior hypogastric plexuses Lymphatic drainage Internal iliac, external iliac nodes, common iliac, and lumbar lymph nodes
- 8. Anatomy of urinarybladder Location Ă Male Ă between pubic symphysis and prostate inferiorly and distal third of rectum posteriorly Ă Female Ă between pubic symphysis inferiorly and uterus, vagina posteriorly Male Female Parts: Body, Apex, Fundus, Neck Surface: Superior, Inferior, Right Inferolateral, Left Inferolateral Angles: Anterior, Inferior, Posterolateral
- 9. Anatomy of urinarybladder Trigone Triangular area of smooth muscle Boarders formed by: Ă Thickened muscle between the ureteric orifices (interureteric crest) Ă Thickened muscle between ureteric orifice and internal urethral meatus Serosa â continuous with perineum Detrusor muscle â 3 interlaced muscle layers that aid in micturition Submucosa â vascular tissue Mucosa â transitional epithelium * Individual with obstructed urine outflow usually come with hypertrophic of the detrusor muscle
- 10. Arterial supply (superior vesicalarteries) Ă Male: Superior and inferior vesical arteries Ă Female: Vaginal arteries Venous drainage Ă Vesical venous plexus. Ă It is a tributary of the internal iliac vein Nerve supply Ă Sympathetic: T12, L1, L2 innervate trigone, ureteral opening and blood vessel Ă Parasympathetic: fibers from S2 to S4 innervate the detrusor muscle Ă Pelvic splanchnic nerve: Relay sensory impulses to the brain from distension of specialized stretch receptor Innervation of urinary bladder
- 11. Urethra Male Ă Length: 20cm ĂParts: Prostatic, Membranous, Penile/Spongy Female Ă Length: 4cm Ă Opens through the external urethral opening found between the labia minora, anterior to the vaginal opening. Internal urethral sphincter Ă Male: Circular smooth fibres under autonomic control. Ă Female: Functional sphincter formed by the anatomy of the bladder neck and proximal urethra External urethral sphincter ⢠has the same structure in both sexes. ⢠Skeletal muscle, and under voluntary control.
- 12. Urethra Male urethra Innervation: Prostaticplexus Lymphatic drainage: Ă Prostatic and Membranous into internal iliac nodes Ă Penile into deep and superficial inguinal nodes Female urethra Vascular: Int. Pudendal, vaginal arteries/veins Innervation: Vesical plexus and Pudendal nerve Lymphatic drainage: Ă Proximal â internal iliac nodes Ă Distal â superficial inguinal nodes Prostatic urethra Ă Receives the ejaculatory ducts and the prostatic ducts Ă It is the widest and most dilatable portion of the urethra. Ă Supplied by inf. vesical artery Membranous urethra: Ă Surrounded by the external urethral sphincter (voluntary control of micturition) Ă It is the narrowest and least dilatable portion of the urethra. Ă Supplied by bulbourethral artery Penile urethra Ă Receives the bulbourethral glands proximally Ă Dilates to form the navicular fossa Ă Supplied directly by branches of the internal pudendal artery
- 13. Physiology of micturition Increasedpressure in bladder caused by accumulation of urine Stretch receptor in the bladder wall send signal send signals to the spinal cord (S2 â S4) via inferior hypogastric nerve Spinal cord then sends signals through same plexus â contraction of detrusor muscle and relaxation of internal urethral sphincter Cerebral cortex imposes voluntary control over this reflex as it controls the relaxation of the external urethral sphincter Ă â150 ml : 1st urge to void Ă 150 â 400 ml : bladder radius increased, but urge goes away Ă 400ml : marked sense of fullness but still controllable Ă 600ml : painful contraction, micturition inevitable
- 14. O B ST R U C T I V E U R O P A T H Y
- 15. Definition Ă Functional orstructural changes/obstruction in any level of the urinary tract that impair the normal urine flow Ă May cause dilatation of the structure proximal to the obstruction Ă Obstruction may be in upper or lower urinary tracts and have corresponding sign and symptoms based on Ă ĚSite Ă Degree of obstruction Ă Duration
- 16. Aetiology Renal causes Congenital Ă Polycystickidney Ă Renal cyst Ă Peripelvic cyst Ă Ureteropelvic junction obstruction Neoplastic Ă Wilms tumor Ă Renal cell carcinoma Ă Transitional cell carcinoma Ă Multiple myeloma Miscellaneous Ă Stone Ă Trauma Ă Renal artery aneurysm Inflammatory Ă Tuberculosis
- 17. Aetiology Ureter causes Congenital Ă Stricture ĂUreterocele Ă Obstructive megaureter Neoplastic Ă Primary carcinoma of ureter Ă Metastatic carcinoma Miscellaneous Ă Retroperitoneal fibrosis Ă Aortic aneurysm Ă Radiation therapy Ă Trauma Ă Pregnancy Inflammatory Ă Tuberculosis Ă Schistosomasis Ă Abscess Ă Endometriosis
- 18. Aetiology Bladder & urethracauses Congenital Ă Posterior Urethral valve Ă Phimosis Neoplastic Ă Bladder cancer Ă Prostate cancer Ă Carcinoma of urethra Ă Carcinoma of Penis Miscellaneous Ă Benign prostatic hyperplasia (BPH) Ă Neurogenic bladder Ă Urethra stricture Inflammatory Ă Prostatitis Ă Paraurethral abscess
- 19. Clinical features Upper UrinaryTract Lower Urinary Tract Symptoms Ă Loin pain Ă Anuria (complete unilateral/bilateral obstruction of kidneys) Ă Polyuria (partial obstruction) Ă Malaise, fever (in case of infection complicating the obstruction) Symptoms Ă Symptoms may be minimal Ă Hesitancy, narrowing and diminished force of urinary stream Ă Terminal dribbling Ă Sense of incomplete bladder emptying Ă Incontinence Ă Infection commonly occurs â increased frequency, urgency, dysuria Ă Constant lower abdominal pain Ă Nocturnal enuresis Ă Nocturia Causes (kidneys â ureter) Ă Infection Ă Malignancy Ă Renal calculi Ă Ureteric stricture Causes (bladder â urethra) Ă BPH Ă UTI Ă Urological malignancy Ă Prostatitis Ă Urethral stricture Ă External compression (pelvis tumor/faecal impaction)
- 20. Physical examination Abdominal examination ĂTenderness (depends on affected site) (costovertebral= pyelonephritis) Ă Ballotable kidney (severe hydronephrosis) Ă Palpable bladder + suprapubic pain (retention) Ă Dull on percussion (acute / chronic retention) Ă Positive renal punch Rectal examination Ă Prostate or uterus pushed backward and downward
- 21. Complications Increased backflow pressure ĂHydronephrosis Ă Hydroureter Ă Renal function impairment Stagnation of urine Ă Predispose to infection Ă Predispose to stone formation Irritation / abrasion / necrosis
- 22. Hydronephrosis Definition Ă Hydronephrosis isan aseptic dilatation of the kidney caused by obstruction to the outflow of urine Extramural Ă Tumour from adjacent structures Ă Idiopathic retroperitoneal fibrosis Ă Retrocaval ureter Unilateral Intramural Ă Congenital stenosis, narrowing of the PUJ Ă Ureterocele and congenital small ureteric orifice Ă Inflammatory stricture Ă Neoplasm of the ureter or bladder cancer involving the ureteric orifice Intraluminal Ă Calculus in the pelvis or ureter Ă Sloughed papilla in papillary necrosis (especially in diabetics, analgesic abusers and those with sickle cell disease) may obstruct the ureter
- 23. Bilateral Bilateral hydronephrosis isusually the result of urethral obstruction, but the lesions described above may occur on both sides. When due to lower urinary obstruction, the cause may be: Congenital Ă posterior urethral valves Ă urethral atresia Acquired Ă benign prostatic enlargement or carcinoma of the prostate Ă postoperative bladder neck scarring Ă urethral stricture Ă phimosis.
- 24. URINARY CALCULI Defined as solidparticles in the urinary system causing pain, nausea, vomiting, hematuria & possibly chills & fever due to secondary infection.
- 25. AETIOLOGY ⢠Dietetic ⢠Deficiencyin vitamin A ⢠result in hyperkeratosis & desquamation of urinary epithelium which provides debris for stone formation ⢠Uric acid foods ⢠Mushroom, fish/prawn, beer/wine, bamboo shoot ⢠Inadequate drainage & urinary stasis ⢠Calculi may form whenever urine is stagnates such as in hydronephrosis or in diverticulum of the bladder
- 26. ⢠Increased calciumexcretion ⢠Prolonged immobilization: skeletal decalcification â â urinary calcium ⢠Hyperparathyroidism â hypercalcemia, hypercalciuria ⢠Lack of stone formation inhibitors ⢠Low levels of citrate & magnesium in the urine make calcium complexes less soluble promoting calcium oxalate & phosphate stone formation. ⢠Renal infection ⢠Predominant bacteria: staphylococci, proteus, e.coli, klebsiella (urea splitting organisms). These bacteria produce urease which can alter urine pH creating alkaline condition which favors stone formation.
- 27. TYPES OF RENALCALCULUS ⢠Calcium oxalate (60%) ⢠Three types of stones are described: â small smooth 'hemp-seed' stones â small irregular 'mulberry' stones â small spiculated 'jack' stones â hard and radio-opaque â Sharp projection: tend to cause bleeding â Surface is discolored by altered blood ⢠Phosphate stone (mixture of calcium, ammonia, magnesium) (33%) â Smooth and dirty white â Typically large 'staghorn' calculi of pelvicalyceal system and some bladder stones. â Radio-opaque
- 28. ⢠Uric acidand urate (5%) â Hard, smooth and often multiple and mutlifaceted â Pure stones are radiolucent â Most uric acid stones contain some calcium, so they cast a faint radiological shadow ⢠Cystine calculus (1%) â Uncommon congenital error of metabolism leads to cystinuria â Often multiple â Pure stones are radiolucent
- 30. RENAL CALCULI ⢠Stonesin renal calyces may lie silent for years until complication (infection) occurs. ⢠50% present at the age of 30-50 y/o ⢠Male:female = 4:3 ⢠Sign & Symptom: ⢠Fixed dull ache, worse on movement ⢠Localised at loin or hypochondrium or both ⢠Haematuria (90% have microscopic hematuria) ⢠Ballotable lump in the loin (if hydronephrosis develops) ⢠If obstruction occur at pelvic-ureteric junction, leads to colicky pain associated with profuse sweating, nausea and vomiting.
- 31. URETERIC CALCULI ⢠Usuallycomes from kidney, most pass spontaneously ⢠Clinical features: ⢠Intermittent attacks of ureteric colic. Referred to groin, external genitalia & anterior surface of thigh. ⢠Impaction at ureteropelvic junction, crossing the iliac artery, juxtaposition of vas deferens/broad ligament, entering the bladder wall & ureteric orifice. ⢠An impacted stone cause more consistent dull pain ⢠Hematuria ⢠Tenderness and rigidity over course of ureter during abdominal examination
- 33. BLADDER CALCULI ⢠Aprimary bladder stone develop in sterile urine; often originates in kidney. ⢠Secondary stone occurs in presence of: ⢠Infection ⢠outflow obstruction ⢠impaired ladder emptying ⢠foreign body ⢠Male are affected 8 times more frequent than female. ⢠Can be asymptomatic & found incidently
- 34. SYMPTOMS:- ⢠Increase frequency â˘Sensation of incomplete bladder emptying ⢠Pain (strangury) (often in spiculated oxalate calculus). Occurs at end of micturition. Referred to tip of penis/labia majora. ⢠Pain worsened by movement ⢠Child may pull the penis and scream with pain at the end of micturition. ⢠Haematuria at the end of micturition ⢠Interruption of urinary stream (d/t the stone blocking the internal meatus) ⢠Cystitis is common
- 36. Approach to investigation Aimsof investigation: ⢠To confirm the presence of stone ⢠To locate the stone(s) ⢠To evaluate any deleterious effects of the stone(s) on renal function and urinary tract morphology ⢠To identify any structural disorders of the urinary tract acting as local predisposing factors ⢠To identify any metabolic predisposing factors
- 37. INVESTIGATIONS ⢠X-ray ⢠âKUBâfilm shows kidney, ureter & bladder ⢠Diagnose radiopaque stones (mostly oxalate stone) ⢠Opacity that maintains its position relative to the urinary tract is likely to be calculus
- 38. ⢠Blood serumlevel for phosphate, magnesium, calcium, urate ⢠Can use the result to predict types of stone involved. ⢠CT Scan ⢠Excretion Urography (IVU) ⢠Can establish presence & position of calculus & function of other kidney ⢠Need BUSE results 1st as with patient that have renal impairment, they cannot cope with the IVU contrast ⢠Pt with creatinine level >250 cannot do IVU ⢠If patientâs BUSE not normal, can do retrograde pyelogram to detect the location of stone ⢠Ultrasound ⢠Most value in locating stones for treatment by extracorporeal shock wave lithotripsy (ESWL) ⢠Can detect upper hydroureter and hydronephrosis (as complication from stones)
- 40. MANAGEMENT ⢠Conservative management â˘Calculi smaller than 0.5cm pass spontaneously unless they are impacted. ⢠If secondary infection occur in upper urinary tract, urgent surgical intervention is needed. ⢠General principle: ⢠Size of stone (0.5cm = conservative tx) / (>0.5cm = surgical intervention) ⢠Location of stone ⢠Non-invasive treatment considered first â invasive treatment â open surgery as a last resort (d/t risk of stricture formation) ⢠Preoperative treatment ⢠Antibiotic treatment starts before surgery and continues after wards.
- 41. â˘Operation for kidneystones: ⢠Modern method of stone removal: ⢠Percutaneous nephrolithotomy ⢠Extracorporeal shock wave lithotripsy (ESWL) ⢠Open surgery ⢠Pyelolithotomy ⢠Nephrolithotomy
- 42. 1. Percutaneous nephrolithotomy â˘Endoscopic instrument passed into kidney by percutaneous technique. Small stones may be grasped under vision & extracted whole. Large stones are fragmented by ultrasound or laser & removed pieces. Usually used for stones >2cm size. ⢠Sometimes combined with ESWL in complex (staghorn) calculi.
- 43. ⢠Extracorporeal shockwave lithotripsy (ESWL) ⢠Crystalline stones disintegrate under the impact of shock waves produced by the ESWL machine. ⢠A stent is placed in ureter to drain the kidney while stone fragments pas to avoid bulky stone fragments impacting the ureter causing obstruction. ⢠Only can be used in stones located at renal pelvis & not more than 2cm size.
- 44. â˘Open surgery: â˘usually forstaghorn stone 1. Pyelolithotomy ⢠Indicated for stones in renal pelvis. 2. Nephrolithotomy ⢠Indicated for complex calculus branching into the most peripheral calyces, & also necessary when adhesions from previous surgery complicate access to renal pelvis.
- 45. URETERIC STONE TREATMENT â˘Pain ⢠NSAIDs (diclofenac & indomethacin) ⢠Indication for surgical removal: ⢠Repeated attacks of pain & stone not moving ⢠Stone is enlarging ⢠Urine if infected ⢠Impacted stone
- 46. â˘Ureteroscopic stone removal ⢠Aureteroscope introduced transurethrally across the bladder into ureter to remove stones impacted. Stones that cannot be caught are fragmented.
- 47. ⢠If stoneis in upper 1/3 of ureter with size >2cm: ⢠Ureteroscopic cannot be done due to high up location ⢠Push bang technique is preferred. The stone can often be flushed back into kidney using ureteric catheter. ⢠A J-stent secures the calculus for subsequent treatment with ESWL ⢠Endoscopic stone removal: 1. Ureteric meatotomy ⢠Endoscopic incision with a diathermy knife, to enlarge the opening and free a stone lodged in the intramural ureter. 2. Dormia basket ⢠Use of wire baskets under image intensifier control. There is a risk of ureteric injury even with small stones. The technique have been replaced with ureteroscopic techniques.
- 49. ⢠Open surgeryfor ureteric stone: 1. Ureterolithotomy ⢠Open or laparoscopic surgical removal of a stone from the ureter ⢠Used in stone at narrowed site (PUJ)
- 50. Bladder Stone Treatment â˘Litholapaxy / Vesicolitholapaxy ⢠Blind lithotrite used to crush bladder stones, an early type of minimally invasive technique. Now includes optical lithotrite, electrohydraulic lithothrite, Holmium laser or ultrasound probe. ⢠Used for stones sized >5cm in bladder ⢠Contraindication: ⢠A urethral stricture that cannot be dilated sufficiently ⢠A contracted bladder ⢠A very large stone
- 52. 2. Percutaneous suprapubiclitholapaxy ⢠The best method to use if not possible to carry out litholapaxy per urethra due to a narrow urethra. 3. Cystolithotomy / Vesicolithotomy ⢠Surgical removal of bladder stones via a lower abdominal incision
- 53. Urethral Calculi ⢠Commonly,the stone is a renal calculus that migrate to the urethra via bladder. ⢠Clinical features: ⢠Sudden pain in urethra soon after an attack of ureteric colic ⢠Blockage of flow of urine. If stone small, the stone can often expel from urethral meatus. Larger stone get stuck. ⢠Sometimes possible to feel a hard lump in urethra ⢠Diagnosis can be confirmed with urethroscopy or bouginage. ⢠Treatment: ⢠A stone in prostatic urethra should be displaced back into bladder (via catheter) and managed by litholapaxy/suprapubic cystotomy. ⢠A calculi in more distal part are removed by basketing under vision or fragmented in situ using electrohydraulic. ⢠A calculi in external urethral meatus (narrowest part), should be treated by urethral meatotomy. ⢠Open removal by external urethrotomy is rarely necessary.
- 54. SUMMARY OF STONEREMOVAL Kidney Ureter Bladder Urethra Percutaneous Nephrolithotomy (PNCL) Dormia Basket Litholapaxy Push Bang Extracorporeal Shock Wave Lithotripsy (ESWL) Ureteric Meatotomy Percutaneous Suprapubic Litholapaxy Basketing Under Vision / Fragmented In Situ Pyelolithotomy Ureteroscopic Stone Removal Cystolithotomy Urethral Meatotomy Nephrolithotomy Push Bang External Urethrotomy Ureterolithotomy
- 55. PREVENTION OF RECURRENCE â˘Patient should be investigated to exclude metabolic factors. ⢠Urine screened for infection. ⢠Investigations appropriate in bilateral & recurrent stone formers: ⢠Serum calcium, measured fasting on 3 occasions (hyperparathyroidism) ⢠Serum uric acid ⢠Urinary rate, calcium & phosphate in a 24-hour collection ⢠Urine screened for cystine ⢠Analysis of any stone passed.
- 56. ⢠Dietary adviceto those consumed excessive: ⢠Milk products (calcium stone) ⢠Rhubarb, strawberries, plums, spinach & asparagus (calcium oxalate stones) ⢠Eggs, meat & fish (â in sulphur-containing protein) should be restricted in cystinuria. ⢠Pt with hyperuricaemia should avoid: ⢠Red meats, oďŹal & fish ⢠And should be treated with allopurinol ⢠Drink plenty of water to keep their urine dilute ⢠Drug treatment only eďŹective in those with idiopathic hypercalciuria. ⢠Bendroflumethiazide (5mg) + calcium-restricted diet.