hydronephrosis, vur,rcc

1. Hydronephrosis, VUR, RCC
Dr Sunil Kumar
Assistant professor
Department of Urology, AIIMS Rishikesh

2. Hydronephrosis

3. Contents
• Definition
• Etiology
• Pathology
• Clinical features
• Special investigations
• Treatment
3

4. Definition
• Dilatation of renal pelvis & calyces with accompanying
destruction of the kidney parenchyma
• Usually due to partial obstruction to the outflow of urine
4

5. Hydronephrosis
5

6. 6
Normal kidney Hydronephrosis

7. Normal Intravenous Pyelogram (IVP)
7

8. Intravenous Pyelogram (IVP) Showing Hydronephrosis 8

9. 9

10. Etiology
• Primary or secondary
• Primary: idiopathic
• Secondary: maybe unilateral or bilateral
10

11. Causes of unilateral hydronephrosis
• Maybe extramural, intramural or Intraluminal
• Extramural:
– Pressure on the ureter by loaded sigmoid colon, gravid uterus, uterine
& ovarian tumors
– Involvement of the ureter by malignant neoplasm outside it e.g.
carcinoma of the cervix, uterus, colon, rectum, prostate
– Aberrant renal vessels
– Idiopathic retroperitoneal fibrosis
11

12. Causes of unilateral hydronephrosis
• Intramural:
– Congenital stenosis or achalasia of the PUJ
– Ureterocele
– Stricture
– Neoplasm of ureter
12

13. Causes of unilateral hydronephrosis
• Intraluminal:
– Calculus
– Congenital folds at the upper end of the ureter
13

14. Causes of bilateral hydronephrosis
• Due to pathologies in the urethra or the urinary bladder
• Causes in the urethra:
– Meatal stenosis
– Posterior urethral valve
– BPH & carcinoma of prostate
– Stricture
– Carcinoma of cervix & uterus
14

15. Causes of bilateral hydronephrosis
• Due to pathologies in the urethra or the urinary bladder
• Causes in the bladder:
– Calculus
– Neoplasms
– Sphincter dysfunction
15

16. 16

17. 17

18. 19

19. Clinical features
• May depend on unilateral, intermittent or bilateral
hydronephrosis
• Unilateral hydronephrosis:
– Dull ache & sense of weight on the affected side of the loin
– Causes of the hydronephrosis
20

20. Clinical features
• May depend on unilateral, intermittent or bilateral
hydronephrosis
• Intermittent hydronephrosis:
– Dietl’s crisis
21

21. Clinical features
• May depend on unilateral, intermittent or bilateral
hydronephrosis
• Bilateral hydronephrosis:
– Features of the causes
– Bilateral renal swelling
22

22. Special investigations
• Straight abdomen of the X- ray
• Excretory urography
• Retrograde urography
• Ultrasound
• Nuclear scan
23

23. Treatment
• Secondary hydronephrosis: treatment of the cause
• Primary hydronephrosis:
– Pyeloplasty:
• Anderson- Hynes
• Culp
• Foley
– Nephrectomy
24

24. 25

25. 26

26. 27

27. Principles of pyeloplasty
• To reduce the size of the renal pelvis
• Excision of the PUJ
• The ureter is attached to the most dependent part of the pelvis
• Watertight closure
• Stented
28

28. VUR
• What is VUR ?
• Pathophysiology of VUR
• Grade of VUR
• Impact of VUR
• Clinical presentation
• Sequele of VUR
• Diagnosis of VUR
• Management of VUR

29. • retrograde flow of urine from the bladder to
the upper urinary tract

30. • Primary VUR
• Secondary VUR
• Primary-deficient tunnel / laterally displaced
orifices
• Secondary-increased intravesical pressure
secondary to neurogenic problems or DESD,
bladder instability, bladder outlet obstruction
(PUV, BPH, CaP, USD)

31. • Ureteric diameter: Sub mucosal ureteric
length=1:5

34. • Impact of VUR
– Predisposition to upper urinary tract infection
– Renal function impairment

35. • Clinical presentation
– Recurrent UTI(Pyelonephritis, Pyonephrosis)
– Features of impaired renal function(Uraemia)

36. • Sequele of VUR
– Loss of renal function,
– HTN
– ESRD

37. • Diagnosis
– USG
– MCU

38. • MCU-Radioisotope

39. • DMSA scan-renal scar

40. Natural history

41. Management
• 1. Spontaneous resolution of reflux is very
common.
2. High-grade reflux is less likely to resolve
spontaneously.
3. Sterile reflux is benign.
4. Extended use of prophylactic antibiotics is
benign.
5. Success of (open) surgical correction is very
high.

42. • Prophylactic antibiotic
• Surgical- Lengthening of sub mucosal tunnel
• Endoscopic treatment-
Deflux/Macroplastique/Collegen

43. Renal cell carcinoma
• Epidemiology
• Etiology
• Histological subtypes
• Clinical presentation
• Diagnosis
• Staging
• Treatment

44. Epidemiology
• 2% to 3% of all adult malignant neoplasms,
• the most lethal of the common urologic cancers
• typical presentation in the sixth and
seventh decades of life
• 97-98% sporadic
• 2-3% familial

45. Etiology
• Tobacco exposure
Obesity
Hypertension
• Familial-
– von Hippel Lindau syndrome(VHL gene on
chromosome 3)
– Many others

46. VHL
• Benign retinal angiomas
• Benign hemangioblastomas
• Clear cell renal cell carcinoma
• Renal cysts
• Pheochromocytoma
• Islet cell tumors
• Malignant islet cell tumor
• Pancreatic cysts
• Epididymis Cystadenoma
• Endolymphatic sac tumor

51. Histological subtypes
• Clear cell carcinoma -70-80%
• Papillary cell carcinoma-10-15%
• Chromophobe RCC 3-5%
• Collecting duct carcinoma <1%
• Renal medullary carcinoma rare

52. Clinical presentation
• In olden days-Not detected until very large or
symptomatic( concelled by Retroperitoneum)
• Now-50% detected incidental

53. • Classical-flank pain, gross hematuria, and
palpable abdominal mass

56. Diagnosis
• USG
• CECT
• MRI
• CD/ANGIOGRAPHY/TES

57. • >15 HU enhancement

58. Robson’sclassification

59. TX Unknown
T0 No primary tumor
T1 ≤7.0 cm, confined to the kidney
T2 >7.0 cm and confined to the kidney
T3 Extend into major veins and perinephric tissue
T4 Beyond Gerota fascis

60. Treatment
• Localised
• <4 cm- Partial nephrectomy
– Active survillance
– Thermal ablation
– Cryoablation
– Partial nephrectomy
• >4 cm
– Radical nephrectomy

62. Locally advanced RCC

63. • Radical nephrectomy ± IVC thrombectomy with or
without Cardiac by pass and deep circulatory arrest/
veno-venous bypass

72. Metastatic RCC
• Debulking/cytoreductive nephrectomy
• Resection of metastasis

73. Management
• Irresectable tumor
• Residual tumor after Cytoreductive
nephrectomy

74. • Immunotherapy: Interferon, Interleukin-2
• Targeted molecular therapy:
– TKI(Tyrosine kinase inhibitor),
– Monoclonal antibody,
– mTOR inhibitor

77. Side effects of TKI
• Gastrointestinal events-particularly diarrhoea,
• dermatologic manifestations such as rash and
hand-foot syndrome,
• constitutional symptoms-fatigue and asthenia,
and hypertension
• bone marrow suppression,
• decline in left ventricular ejection fraction
• hypothyroidism

78. • Thank You