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Upper Urinary Tract Authors (Gearry)Thanks to our partners! Learning Objectives • ▪ Overview of the anatomy of the kidneys, ureter, bladder and urethra in both males and females, and compare and contrast the anatomical differences between these, especially during procedures such as catheter insertion ▪ Understand the anatomy of the kidneys as well as their neurovascular supply ▪ Recognise the signs and aetiology of renal calculi as well as the medical and surgical management of this ▪ Differentiate between UTI and pyelonephritis and identify the most causative organisms ▪ Recall congenital abnormalities of the kidney and describe the surgical significance of this ▪ Describe the mechanism of renal cell carcinoma and be able to recognise clinical signs of this (L sided varicocele in males) ▪ Understand the mechanism of hydronephrosis and the management of this ▪ Recognise acute and chronic urinary retention and recall the management of this ▪ Recall TOWC procedures post surgery ▪ repairiate the formation of hernias and describe the difference between deep and superficial inguinal as well as their surgicalAnatomy of kidneys • The urinary system is used to balance out electrolytes in the body • Kidneys are a retroperitoneal organ situated at levels of T12 to L3 • Kidneys layers(Deep to superficial)= Renal capsule → perirenal fat → renal fascia → pararenal fat • Top of Renal pyramids → Renal papilla • Renal papilla links to the minor calyx • Several minor calyx → Major calyx (2-4 in each kidney) • Urine passes from major calices into renal pelvis where it drains into ureterNeurovascular Supply of Kidneys (arteries) • The kidneys are supplied with blood via the renal arteries • The renal artery enters the kidney via the renal hilum • Divided into anterior and posterior divisions. • Anterior divisions divide into interlobar arteries at minor calyces • At the base of Renal pyramids flows into arcuate arteries • Interlobular arteries lead into afferent arterioles that bring blood to the glomerulusNeurovascular Supply of Kidneys (capillaries) • Efferent arterioles form capillaries that facilitate absorption and secretion of electrolytes. • Peritubular capillaries (outer two-thirds of the renal cortex) • Vasa recta (Inner third of the renal cortex)Neurovascular Supply of Kidneys (veins) • Capillaries→ interlobular veins → arcuate veins → interlobar veins → Renal vein • Renal vein drains into inferior vena cava at L2.What is the correct sequence of blood vessels carrying blood from the renal artery into the nephron? a) Renal artery → Interlobar artery → Arcuate artery → Interlobular artery → Afferent arteriole b) Renal artery → Interlobular artery → Arcuate artery → Afferent arteriole c) Renal artery → Arcuate artery → Interlobar artery → Interlobular artery → Afferent arteriole d) Renal artery → Arcuate artery → Interlobular artery → Afferent arteriole e) Renal artery → Interlobular artery → Interlobar artery → Arcuate artery → Afferent arterioleWhat is the correct sequence of blood vessels carrying blood from the renal artery into the nephron? a) Renal artery → Interlobar artery → Arcuate artery → Interlobular artery → Afferent arteriole b) Renal artery → Interlobular artery → Arcuate artery → Afferent arteriole c) Renal artery → Arcuate artery → Interlobar artery → Interlobular artery → Afferent arteriole d) Renal artery → Arcuate artery → Interlobular artery → Afferent arteriole e) Renal artery → Interlobular artery → Interlobar artery → Arcuate artery → Afferent arterioleNeurovascular Supply of Kidneys (lymphatic system) • The superficial lymphatic vessels form a plexus under the renal capsule known as the subcapsular lymphatic plexus. • The renal lymphatics then drain directly to the lumbar lymph trunks and to para-aortic nodes • Clinically useful in surgeries especially renal transplant.Neurovascular Supply of Kidneys (innervation) • The kidneys receive innervation from both the sympathetic and parasympathetic divisions of the autonomic nervous system • Sympathetic innervation primarily from the renal sympathetic plexus • Sympathetic stimulation regulates renal blood flow, glomerular filtration, and renin release • Parasympathetic innervation from the vagus nerve • The role of parasympathetic innervation is less well-definedAnatomy of Ureter and Bladder Ureter • The ureters are muscular tubes that carry urine from the kidneys to the bladder. • In both males and females, each kidney has one ureter. • The ureters are more lateral in females to the urethra than in males Bladder • The bladder is a hollow, muscular organ that stores urine. • In females (a), it lies anterior to the vagina and inferior to the uterus • In males (b), the bladder is anterior to the rectum and superior to the prostate gland • In males, the bladder neck is surrounded by the internal urethral sphincter and the prostate gland • In females, the bladder neck is surrounded by the urethra and the pelvic floor musclesAnatomy of Urethra Urethra • The urethra is the tube that carries urine from the bladder to the external urethral orifice, where it is expelled from the body during urination • In males, the urethra is longer (20 cm) and more complex compared to females (4cm) due to its role in both urination and ejaculation • ^ reflected in catheterisation where smaller catheters are used for females • More information about the surrounding structures in tomorrow’s sessionWhich of the following medications is commonly used to facilitate the passage of kidney stones by relaxing the muscles of the ureter and promoting stone expulsion? A) Nonsteroidal anti-inflammatory drugs (NSAIDs) B) Alpha-adrenergic blockers C) Antibiotics D) Proton pump inhibitors (PPIs) E) Antispasmodic agentsWhich of the following medications is commonly used to facilitate the passage of kidney stones by relaxing the muscles of the ureter and promoting stone expulsion? A) Nonsteroidal anti-inflammatory drugs (NSAIDs) B) Alpha-adrenergic blockers C) Antibiotics D) Proton pump inhibitors (PPIs) E) Antispasmodic agents Kidney Stones • Crystal aggregations in urine causes kidney stones that results in renal colic • May be caused by dehydration, dietary factors, medical conditions such as gout, family history etc. • Signs and symptoms: • Non-contrast CT KUB should be performed on all patients, ➢Severe flank pain within 14 hours of admission ➢Haematuria ➢Urinary symptoms ➢Nausea and vomiting Useful tip for exams- Calcium ➢Urinary Tract infections Oxalate commonest composition of stones and is ➢Fever and chills opaque in radiographs ➢Painful urinationManagement of Renal Stones • Watchful Waiting • Medical- (NSAIDS, antiemetics, antibiotics or Tamsulosin) • Surgical: - Extracorporeal shock wave lithotripsy (ESWL) - Ureteroscopy and laser lithotripsy - Percutaneous nephrolithotomy (PCNL) • Open surgery (rare)Which of the following pathogens is the most common cause of uncomplicated urinary tract infections (UTIs) in otherwise healthy individuals? • A) Staphylococcus aureus • B) Escherichia coli (E. coli) • C) Streptococcus agalactiae (Group B Streptococcus) • D) Pseudomonas aeruginosa • E) Candida albicansWhich of the following pathogens is the most common cause of uncomplicated urinary tract infections (UTIs) in otherwise healthy individuals? • A) Staphylococcus aureus • B) Escherichia coli (E. coli) • C) Streptococcus agalactiae (Group B Streptococcus) • D) Pseudomonas aeruginosa • E) Candida albicans1.Calcium oxalate b) Sodium chloride c) Potassium sulfate d) Iron phosphate 2.High fluid intake b) Sedentary lifestyle c) Low dietary sodium intake d) Familya) history of renal stones 3.a) Calcium oxalate b) Uric acid c) Cystine d) Struviteh a urinary tract infection? 4.tract? a) Hematuria (blood in urine) b) Dysuria (painful urination) c) Polyuria (increased urination) d) Anuria (lack of urination) 5.Which imaging modality is typically used to diagnose renal calculi? a) X-ray b) Ultrasound c) Magnetic resonance imaging (MRI) d) Positron emission tomography (PET) Urinary T ract Infection • UTI typically refers to an infection of the lower urinary tract • Causes: E. coli, Klebsiella, Proteus, and Enterococcus species • Signs and symptoms: • frequent urination, • urgency to urinate, • burning sensation during urination, • cloudy or foul-smelling urine, • and pelvic discomfort • Red flag symptoms such as haematuria, loin pain, rigors, nausea, vomiting, and altered mental state may indicate more serious infection • 1st line management is with oral nitrofurantoin or trimethoprim ➢3 days of antibiotics for simple lower urinary tract infections in women ➢7 days of antibiotics for men, pregnant women or catheter-related UTIs Pyelonephritis • Pyelonephritis is a bacterial infection of a kidney • Causes include E.coli, Klebsiella pneumoniae and Proteus mirabilis • Signs and symptoms: ➢Fever ➢Flank Pain ➢Abdominal Pain ➢Nausea and Vomiting ➢Urinary Symptoms • Treatment with antibiotics for 7-14 days and if vulnerable admit Congenital abnormalities of Kidneys • A kidney may be missing (renal agenesis) • A kidney may have formed abnormally (renal dysplasia) • A kidney may have fluid-filled cysts (polycystic kidney disease or multicystic kidney disease) • A kidney may be abnormally small (renal hypoplasia) • A kidney may be joined to form a horseshoe kidney • Duplex kidney • Surgical interventions may be necessary to address complications such as Urinary tract obstructionsWhich of the following congenital renal anomalies is characterized by the presence of non-functional kidney tissue with multiple cysts and absence of normal renal structures? • A) Horseshoe kidney • B) Medullary sponge kidney • C) Autosomal dominant polycystic kidney disease (ADPKD) • D) Renal agenesis • E) Multicystic dysplastic kidney (MCDK)Which of the following congenital renal anomalies is characterized by the presence of non-functional kidney tissue with multiple cysts and absence of normal renal structures? • A) Horseshoe kidney • B) Medullary sponge kidney • C) Autosomal dominant polycystic kidney disease (ADPKD) • D) Renal agenesis • E) Multicystic dysplastic kidney (MCDK)Renal Cell Carcinoma • Renal cell carcinoma (RCC) accounts for >80% of all kidney cancers • predispose to a variety of benign and malignant tumourssor gene • Dysregulates Hypoxia-inducible factors(HIFs) • Obesity, smoking and hypertension • North American and European ethnicityRenal Cell Carcinoma signs and symptoms • Classical triad: • Flank pain, • Haematuria • Palpable abdominal mass • Left sided scrotal varicocele • Lower limb oedema • Paraneoplastic syndromes • Night sweats, fever, weight loss and fatigue • Based on staging treatment can vary but surgery is main management in local disease.Hydronephrosis (mechanism) • Swelling of kidneys due to urine buildup • Obstructions • Urine reflux Hydronephrosis (management) • 1 line = Ultrasound • Acute obstruction -> nephrostomy tube • Chronic obstruction -> ureteric stent or pyeloplastyAcute Urinary retention • Medical emergency • Causes: ➢ Benign prostatic hyperplasia (BPH), ➢strictures, ➢ medications (e.g. anticholinergics and tricyclic antidepressants) ➢UTIs • Signs and symptoms: ➢Unable to pass urine ➢Lower abdominal discomfort ➢Delirium Acute Urinary retention • Investigations: • Bladder ultrasound, • DRE exam, • Urinalysis • Urine MCS • Management: Decompress bladder through catheterisation after this treat underlying cause • Complications such as post-obstructive diuresisChronic Urinary retention • Long term • Signs and symptoms: • Frequency, • Hesitancy, • Incontinence • and dribbling • Many patients are asymptomatic • Similar causes and management to acute urinary retention • Complications such as post-obstructive diuresisA 70-year-old male presents with a history of progressively worsening urinary symptoms, including difficulty initiating urination, weak urinary stream, and a sensation of incomplete bladder emptying. He denies any recent urinary tract infections or hematuria. Digital rectal examination reveals a palpable enlargement of the prostate gland. Which of the following diagnostic tests is most appropriate to confirm the diagnosis of chronic urinary retention in this patient? • A) Renal ultrasound • B) Urinalysis • C) Uroflowmetry • D) Prostate-specific antigen (PSA) test • E) Post-void residual (PVR) urine measurementA 70-year-old male presents with a history of progressively worsening urinary symptoms, including difficulty initiating urination, weak urinary stream, and a sensation of incomplete bladder emptying. He denies any recent urinary tract infections or hematuria. Digital rectal examination reveals a palpable enlargement of the prostate gland. Which of the following diagnostic tests is most appropriate to confirm the diagnosis of chronic urinary retention in this patient? • A) Renal ultrasound • B) Urinalysis • C) Uroflowmetry • D) Prostate-specific antigen (PSA) test • E) Post-void residual (PVR) urine measurementT rial without Catheter (TWOC) • Catheter is removed to assess bladder emptying • Monitored a passing of urine three times • Helps assess treatment moving forwards- catheterisation or medicationHernias • Organs or tissues protrude through abdominal opening or weak area of body cavity • Types of hernias: • Inguinal, • Femoral, • Umbilical, • Incisional etc. • Can be caused by weak abdominal wall muscles • Diagnosis by physical examinationSuperficial inguinal hernia • Known as ‘indirect inguinal hernia’ • Abdominal content enters the deep ring of the inguinal canal and exits via the superficial ring • May descend into scrotum or strangulate • Open or laparoscopic mesh repair of herniaDeep inguinal hernia • Known as ‘direct inguinal hernia’ • Abdominal content enters directly through a weakness in the posterior wall of inguinal canal • Can still become strangulated • Open or laparoscopic mesh repair of herniaA 65-year-old male presents with a bulge in the groin that increases in size when he coughs or strains. Physical examination reveals a mass protruding through the superficial inguinal ring that can be reduced. Which of the following is the most likely diagnosis? A) Indirect inguinal hernia B) Direct inguinal hernia C) Femoral hernia D) Umbilical hernia E) Incarcerated inguinal herniaA 65-year-old male presents with a bulge in the groin that increases in size when he coughs or strains. Physical examination reveals a mass protruding through the superficial inguinal ring that can be reduced. Which of the following is the most likely diagnosis? A) Indirect inguinal hernia B) Direct inguinal hernia C) Femoral hernia D) Umbilical hernia E) Incarcerated inguinal hernia@supta_uk @SUPTAUK www.supta.uk