Renal & Urinary Tract Intervention - IR Bites Teaching Series



This on-demand teaching session by Dr Usman Mahay is tailored for medical professionals and focuses on the genitourinary system and relevant interventions. It covers topics from anatomy and risk factors to imaging findings, clinical care and follow-up. Using imaging such as radiographs, ultrasound and non-contrast CT imaging, medical professionals can learn how to diagnose obstructions due to stones, tumours, or fibrosis and understand the role of ureteric stents. At the end of the session, there will be a discussion of tumour and ureteric injury and the IR treatment options. Join us to learn more and to understand how to properly assess and manage these threats.
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Learning objectives

Learning Objectives 1. Understand the anatomy of the urinary tract 2. Identify common causes of ureteral obstruction 3. Explain the role of imaging in diagnosing ureteral obstruction 4. Describe characteristics of hydronephrosis on imaging 5. Understand the management and treatment options for ureteral obstruction and hydronephrosis
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, Wrong. Good evening. My name's Chris. I'm enough to down in Taunton. Somerset, welcome back to another by our bias session today. Tonight, this evening or even this morning if you're watching your own catch up on this session is on genitourinary interventions. So things to do with the renal trapped on hand over now to our speaker is man thank you for hosting and know this session on the last one was absolutely fantastic. And if you haven't seen that one, then please, do you watch on capture on yeah, 100. Over. Uh, he's a ST six down, up, actually from May in the West Midlands and on is gonna teach you about the renal track today. Said thank you is Mom, You want to take over, We'll meet myself. Sure. Thanks very much. Chris. Thank you again. Toe ir juniors for the invite. So this topic again is part of a serious off lectures or teaching sessions. Getting to the service. The interventional radiology. Quickly. For medical students, this specific presentation is on genitourinary Interventions on hips should be enough time to also squeeze in some information about testicular vein embolization. So, again, this is the curriculum and in the corner you'll find a references and on links to pretending to the slide. This is where you can find the interventional radiology curriculum for medical students developed by Sir See again. Like other sessions in the previous session, we're gonna use this format off clinical presentation, including classifications where it's relevant. Imaging findings before intervention. I are treatment options, clinical care and follow up. It's a clinical presentation off ureteral obstruction, so it's often this occurs due to a renal tract stones tumors, which could be within the collecting system or outside, causing ureteral obstruction or other processes such as fibrosis. Once there's irritable obstruction, this conclude, too hydronephrosis impaired renal function and evil rupture of the renal collecting system. Other reasons for why one made need a nephrostomy is due to your new tract leakage, which can occur for your only diversion following urinary tract. The kitchen, which can happen due to abdominal trauma or Tradjenta X injury. As from the last session, similar theme is going through a bit of anatomy. What the urinary tract is there. What does it do? They have products of metabolism and toxic waste. Elimination from the kidneys. Urine is connected. It's then transported by the ureters to the bladder where it's stored and then expel through the urethra. This is a nice, simple schematic diagram showing very basic anatomy. Again, you see the kidney in relation to it's vessels. The ureter is tracking down to the urinary bladder and the course that they take. So as we as touched on earlier stones and team is probably the most common causes or leading to ureteral obstruction that we see in practice or I've seen in my limited experience in practice on you can also get cases of fiber. It's for braces. Well, look at hydronephrosis and go through some images with regards to that. But again, it's important pressure. Building up in the system could cause renal impairment and rupture of the collecting system. So how do stones present renal colic? Get a classic presentation of loin to growing pain on either side? Uh, can sometimes be by natural with you got sticky matures more likely to be microscopic, which is picked up on the urine dip as opposed to macroscopic key material, which is visible if the stone is they're stagnant urine and hold up in the collecting system sepsis can develop where patients can present with profound urosepsis. It's on deed to be managed appropriately. They're multiple risk factors for stones, you know. One of them includes at a low fluid intake. So that's a reminder for myself and others reviewing and watching swimming. To try and keep hydrated as much as possible, the stones can impact in various parts or off the collecting system. You might get a Kayla Seal stone, however, this may to stay there, not cause any trouble. Picked up, incidentally, on imaging done for other reasons and may not lead to any obstruction once. If it's fragments or drops down further down into the uh, collecting system, it may then lead to obstruction, Um, and particularly when it goes down the ureter, your uric stone, or it impacts at the V. U J B Skill Your turn junction, which then would cause hydronephrosis back up about it cause the kidney to swell up, have some inflammatory changes around it. Majority of patients are young or, you know, in that sort of age 30 to 60 bracket. It's more prevalent in males. Again, there are various types of stones, although most of them contain some calcium, which is important in with regards to how we imaged. Um, so talking about imaging, this is what is what it mentions in the curriculum. Ultrasound, a non contrast enhanced CT are useful to identify stones. Calculus, as they said they are mainly based on or made off, contain calcium, which is really a pain can can be picked up on imaging. We've mentioned CT hair because plain films have historically being used and things like I have used. That way you can see contrast on the on radiographs, but the low dose techniques for noncontrast ct more commonly used on a Zafer first line. There is a role for you to ct urogram fee, where you can give a contrast and then delayed phase, which, if there is some doubt of the diet diagnosis, helps to delineate or, you know it shows the collecting system and image better on can determine the cause of the obstruction if there is doubt with regards to any stones. So Stones Imaging Select said most contained counseling the radio opaque, historically plain radiograph for I've you, um, modern techniques. You can use ultrasound. You may pick up it, Incidentally, on other findings, and you may be able to identify a calculus on ultrasound. However, uh, the main thing when they present TD department with pain. Renal colic, a noncontrast CT can be performed and quickly. You can quickly come to a diagnosis often obstructed collecting system secondary to, uh, stone disease. And like I said, there are some other imaging modalities which are less often used. But I do have a role. Plain radiograph shows this large staghorn calculus. You could see the nature of captain the radio, opaque nature of it. So again, it's very good to pick it up on a radiograph if required. That noncontrast ct is is much more sensitive. Another radiograph showing another stone and here, except, you know, is starting to use an IV. You study on, you can see here on the plain film there is. Ah, I'm not sure how well this projection, your screens, but a hint of calcium, a stone there. And as you do this that the test, you can see that this holdup of urine, with contrast with in the ureter on da da, agree harder for sis with filling defect. We know it's area around the stone where urine is O. C. Being held up, and you could see the time difference along there so more than techniques. So what we use commonly practiced now with one contrast, low dose CT. Maybe you can see even on a on a contrast scan, for example, you can also pick up very dense calculate. A Got bilateral stones is another example of a calculus, and this is in fact, in a horseshoe kidney. That's a configuration of the kidney here, which predisposes or increases the risk for renal tract stone disease. Another CT here showing it a calculus. Acting up the level off the right to the security junction, I briefly mentioned to me as it's essentially be a topic or lecturer in it of it's own essentially simple way to split up. The tumors, which may be causing obstruction, are intrinsic tumors within the collecting system, causing back pressure up to the kidney hydroureter hydronephrosis What could be extrinsic? There are the pelvic organs, structures within the pelvis or by adjacent to the ureter, which can cause mass effect. Things like I need Malignancies are common in females. Patients on even Mel, you're you're a gentle is prostate cancer for example, if it's massively enlarged or colorectal tumors, so there are various teams which can cause it, but it's simple way to think of it. Is there something within the collecting system which is causing the Jim according the blockage, or is it something outside I mentioned? Fight fibrosis? Retroperitoneal Fibrosis is uncommon fibrotic reaction, but we do see it can present with ureteric obstruction imaging again historic imaging, which on a plane radiograph here with with contrast, you can see medial deviation of the mid ureters. That's a sign seen with retroperitoneal fibrosis again modern techniques or what we use more common now. CT. You could see this fibrotic reaction around, and this patient has had ureteric stents in the past, and you can just see them here has dots in the actual plane on. We'll touch on the role of ureter extents on a later on this talk. So Brady ology is not pathology, but it's good to understand, or as much as possible, the pathology involved. So Hydronephrosis is a specimen with hydronephrosis is to be a little bit, but then tickle meticulous, um, terminology. You know there's 100 of throws is delicious kidney or hydroureter dilation. You return in his hydronephrotic Tosis. But essentially, the main thing is that pressure causing dilation back pressure in the kidney, which could lead to renal impairment on D essentially use the patient becomes can become profoundly septic. With these things, Hydronephrosis and itself could be congenital acquired. But we're not gonna touch with congenital in this in this talk, but it's more more of the acquired causes. Ultrasound imaging Very good to identify. Hydronephrosis. It's again touching on the benefits of out found. It's portable. You can take it. You know some patients. It's profoundly septic in PD I to you to take the machine over. It can easily identify hydronephrosis on. It is also part off the planning for gaining access when you're forming in the frost to me. So here you can see a large or, you know, as in the collecting system is dilated in keeping with hydrated versus CT imaging again dilated collecting system in keeping with hydronephrosis bilaterally in this image, hair on a single girl sequence again, you see hydronephrosis on this noncontrast ct of your associates, swelling of the kidney and some fat stranding changes around the paranoia trick in the permanent vision again. Again, there's a lot of pressure on hold up in your and do two obstruction, low down rupture of the collecting system can happen, and you can get fluid around the kidney, and this is an example off that on renal impairment is very important. You know, these patients can, uh, have a a significant drop in renal function in such a short period of time tumor and ureteric injury. So I am a cardiogenic injury. But essentially, if we're looking at it, conceal it is a disruption of the ureter. This extra visitation off your you know, there's there's contrast outside the collecting system in keeping with injury, and that can happen with drama. Or we were just a particular surgeries where they're operating close to your attorney. It's It can be quite challenging. Unfortunately, the ureter can be injured that way, so moving onto the eye are treatment options. This is describing her pretty much on a frost a me ultrasound guided punches used to access the Calix can be done directly under fluoro guidance. However, ultrasound is used as the modality choice away in my experience. Anyway, to access a Calix on, um start the procedure that way, with regards to safe access into the collecting system, eso and the frost. Any catheter can be placed, which is a tube within the, uh kale Kale X or in the collecting system left in Reno. Pale pelvis on that allows urine to be diverted in the case of ureteric injury or release relief. The pressure from the kidney in hydro. A frantic situation in 100 versus on a loud drainage. External drainage off the urine in the acute phase, A year to extent could potentially be placed in the same sitting, and we'll go through about go through a later one and how we do that. But in a patient who's septic, you might want to hold off putting a ureter extent in straight away, and you can do as a two step procedure in the frost. In the first of our system, settled down love infection, cute infection to settle down and then bring back to your your trick for you to extent in session A later on if we quiet. But there are some instances where you may may be done collectively or may be done in one step. In one sitting where you can do in a frost to me and you to extend it placement. Well, essentially, the nephrostomy gives you access. And then from there you can then place you to extent. So what is enough for us to me, simple terms And that for us from the kidney ostomy forming a new open opening where it's elimination of off waist and again just saying the importance of interventional radiology and clinically managing these patients in A in a setting where you know, this procedure can be done using it aseptic technique. So no frost, um, it could be done open where we're not gonna touch that. But output focus here is on percutaneously. Uh and then for us to me in session. Look at something. Indications which we have covered, um, to some extent extracted system importance off consenting a patient. And also, you know, this is just going back to principles of consent as well, including all available options, including doing nothing with regards to this in a stone disease, there may be option to do a retrograde stent by the urologist, where they go in a retrograde again meaning against the flow of the urine. So bottom up on, but we often do anti great, so in the direction of the urine. So so for the talk down, antibiotics is very important. Prior to proceeding with the frost to meet critical in septic, patients have them optimized in terms of their sepsis care. These patients can be profoundly sick on in that may warrant HD you intensive care input as well. And so it's important that they're sepsis, is is initially managed before they attend for enough ostomy or, you know, in some what a stable condition on. But there's no harm or it's. Actually it's encouraged, and it's a great importance that if you need help, you know, ask for help in terms of the aesthetic support with the last technique, as I mentioned in in the previous talk in this Siris stopped, stare and stop plant plant plant is a really important to plan review the image in that's available to you so you pricey T scan. See how you can plan your access into the kidney ultrasound scan just prior, but again, just go through your consent checklist, which includes having the antibiotics done ideally immediately before the procedure again. Ideal Well told you one patient be prone, but in reality it's very difficult to have all your patients prone and there will be some compromising from it in position. But it shouldn't be a compromise in terms of you doing the procedure safely, where you should have still have a safe window and to the best you can to get a patient in a safe position to proceed. Accepted technique. Do cases under local anesthetic? Answered a shin. It's sometimes given boutin me to patients some a favor, not to give it on. Some patients tolerate it under local city, but if you have, the option should be offered. And again, it's something like giving that does alarm or something to relax. The patient can help steering. So this time we're was staring it tube into the kidneys and the frost in the tube, and then stop as in You know what, you're gonna how you gonna follow this tube? You've left a foreign body into the kidney, so it's very important that these patients do have appropriate after care again. Back to note sound image. How we're gonna plan to sort of get into a K licks again. You can use ultrasound. Get good window and prepare your, uh this is, after all, everything so prepared aseptic technique give you a local anesthetic, and then you can also give local assay right down to the kidney. And this gives you an idea in terms of your approach. So there is mentioned off this in terms of technique. Is a vascular playing the road? Oh, there's a section arena Franklin between to the anterior posterior. Where's relatively a vascular again. This would be an ideal scenario, but sometimes and then it keeps of kick situation. You know, be in a patient with sepsis where the frost, um, is required. Other areas you could still go and access, and you may have to in those Sinus areas. But again, you know, ideal. If you can try and target the relatively a vascular area, and then that's the way to go. So needles inserted into a Calix under ultrasound guidance, you can imagine another sound probe there. Once you're in, you can inject some contrast at this point to mention you don't need somebody to stone disease and septic. You might get some pyuria on return, which in sample and send off. But then You have to be very careful in injecting contrast that some may say not to inject any contrast on See how you're wired passes down, but to get a, you know, gentle amount or, you know, small band off contrast can give you I think you they confirmed that you win the collecting system on Do you can lend proceed further because at this point, you're using a thin needle on if you try to. If you're not in the right place and you may cause damage to the urinal prank, a mole goes some minutes. You you can you can cause a lot of damage if, if you're not sure where you're at next step, I guess in this is part off the seldinger technique, which I have explained in a previous talk. Once you got you, you need only can put a wire through ideally again. You want to try and go down to the ureter and placed the wire on the needle Bit will come out in your left with safe access wire. You could potentially dilate the tract if required, if sometimes it's very difficult in terms of the tissue planes that you're going through. But ultimately final position. Here you can leave a pigtail part of the catheter locked within the renal pelvis, and then you can attach a urine, a bag, a drainage bank at monitor your upper. Initially, you may find some blood stained urine, which is normal, and then in eclairs within a day or two. This is an example off a drain with the PICC tell again we call it the Frost to me tube. Often some of these dreams are multipurpose on can be used in other, uh, parts of the body. Okay, so the next step or next part off the curriculum mentions is your toe extending. I've already touched about in terms off flow. Retro gait is a remake of urologists. We're gonna touch here on empty grade, your toe extending. And this is just a plain radiograph showing bilateral nephrostomy he's on. You've got these battery of tricks sense a stent so J J stent the various names, But essentially, it's a tube from the renal pelvis down into the bladder and allowing facet of urine past the obstructing area. It creates a passage down to the bladder, some fancy using using the scanner and stuff again it might be seen as a gimmicky thing, but that's what your extensive kind of like. Why do we do them? You can get strictures along the ureter and you get hold up off urine blocks. Certainly indications for it, but essentially again is to try and, um, restore urinary drainage from urine drainage from the kidney down to the bladder through it's it's natural course as close as possible. How do we do it? So if we go back So in terms of when we initially put the needle into three K licks me again, put down lower Calix, it may be reasonable. You might have to get through Interpol. We don't have to go to the upper pole. Um, and this is what probably want it touch on one and took my sheets. Is PCN L. Dennis Nephrons Thought is, you know which you're just pretty much conduce, but I asked, can be involved in terms of access back takes meticulous planning because you're putting larger sheets in over goes to, um your toe extents in a six French eight French news. Nine French sheets you can use a standard sheeting is appeal. Where she's the point is once you've got access or if the patients coming back you can put a wire used to exchange over through your frosting YouTube that's already in place or from the initial in a puncture. Access through a tube and secure access with the sheath and talking about staring. Here. You want to find your way. Find a picker suitable capita Teo, get your way down from the renal pelvis past the stenosis will stricture into the bladder on again. Using a suitable wire is an example of a European extent. Once you've got safe access into the bladder, you've navigated your way through. You can then deploy a year to extent. It does come with strings, which he cut one end and carefully targeting. Go back for the for the methadone deployment again, going into the intricacies and the details off deployment. I would strongly encourage you and advise you to go and find on placement your interventional radiology department. Find out when the year too extensive on or when they're booked up. They're elective or if there are, if you happen to be around, there's one happened. Acutely. Get it, get into the room and see how it's done. I've given a put this image. Here's a radiograph. What I'm trying to show him. You got the ureter extent, But is this other tube here? You may think, Why are we leaving? And that frosted me to been. It's known as a covering the frost, a me tube Teo. Allow again the system to to heal. Allow the stent to work, and you give it time. It may initially be capped off. We may be left on free drainage for a couple days and then capped off and seeing how the patient gets on in terms of the clinical course of the biochemical markers and seeing how the renal function's doing Latin, a forced to me or covering the frost motive, which is often a non locking to you, can then be removed and in terms of removal, which will touch him, touch upon later on as well. In terms of follow up is that is really important but also be done under fluoroscopic guidance. Because you do not want Teo try and pull out a tube, it catches on to your to extent on, you know you're causing mysteries of pain, and then I was pulling out the ureter extent, so that's off great importance on here. You can see once functioning, you can leave in June. Got a couple of years or extents. So in terms of follow up that moves it nicely, so patient should be observed over night. As it says in the curriculum. In terms of bed dress, they they maybe they may start mobilizing after a few hours. If everything's going well and it's a smooth some never seen them even watch changing or quite close to period observation after the initial, uh, frosting replacement. The first week after should be exchange at least six months or if it malfunctions, we'll just touch on that here. But initial care for frosted you to extend how everything is done. One step, two step you look at for early complications. Pain, infection, bleeding Bleeding is important way. Don't always see the blood vessels so you might not have. You may not have gone through a relatively a vascular plane and to go watch out for bleeding sepsis. Patient with stone disease that can become profoundly septic in It's a goat and have a septic shower on. That's very important to pick up early and manage your to extents can get in cross state and blocked tubes can fracture. It can move around etcetera. But, you know, just watch out for the immediate, you know, on later complications, observations and follow up. Just briefly touched on nephrostomy tube exchange or removal mentioned tea. My are, um, again trying to get it under safely under fluoroscopic guidance, you take extent exchange world you can look at, like on a lot of this, You could say I mean the first in exchange of things that are off a book within three months. But we found with the gas the pandemic situation covert 19 and the periods way these elective procedures cancelled, we found that, actually, some of them the tubes do an elastic longer. But, you know, three months for enough force to me to exchange in centers where I've trained it, it's quite common time for so if time allows, which I think we're doing wasn't doing well for time. I wanted to cover this with the prostate artery embolization talk. But however, that was it a topic which required or you know, it took mortar time on D was unable to cover it. So moving onto iron men's health, So we covered prostate artery embolization in the last session. There is a section on the curriculum which talks about good model vein embolization and, for one, understanding, previous slides. It's been a very when, Ah, very, very nimble ization have been covered. And in this short section, I'm gonna talk about look at testicular vein embolization so you cannot have a nimble Is a shin in particular focus on testicular vein embolization again, that's the curriculum. Same format to be followed. Clinical presentation, bleeding classification. So in this section off the curriculum, says insufficiency of the gonadal veins that can lead to testicular varicosities with subsequent pain and infertility in men, said an actor, Me again good venous network plexus venous network drains. The test is if you didn't miss. He's come together for testicular veins, which also known as internal spermatic veins when they become dilated and okay, diagnosed with a varicocele on become dilated because off a number of cook causes being maybe insufficiency of the valves. That may be a primary or secondary, which ruled go through shortly. Going back to the point in terms or fertility, I think, um, a number off mails, and this is the general population in terms of 15% of males can have a varicocele a testicle varicocele Uh, and it's in terms of being here. Some fertile, infertile man. Have a box easy. If you're looking at these figures, there is a relationship or association with regards to these, but I want to sort of in a touch upon it here in terms of managing these patients with an embolism, a shin procedure and whether that improves fertility in such cohort patients. Again, a lot of work is being done, but it's there. And so it's an option that can be offered to the patients they can present with a scope to amass. Often described as a bag of worms, you know, towards the end of the day could be worse and then cause pain. And, you know, certainly there's a role in terms of symptomatic relief. Performing testicular vein embolization. Yeah, um, again, Testicular atrophy is another way which in which it can present. So the Viagra seal is dilated veins, which increases the temperature increase blood flow, increased temperature. This disturbance to the firm. A regulation on beach can affect spermatogenesis, so the testicles hang out outside from the body at a cooler temperature 35 degrees. And that is from what I read is in terms of spermatogenesis but dilated veins and then increased bubbled back and increase, um, the temperature by a couple of degrees to around body temperature in it that can indoor effect negatively spermatogenesis. So I mentioned the varicose who could be the primary or secondary to other reasons, probably being very comfortably. The insufficiency of the house by a natural varicocele on are not uncommon. They do a care isolated left again care if in fact you have a nice, elated right, it could be a rare course. You gotta think secondary. Is there something compressing on the vein, either on abdominal, pelvic tumor causing dilation or the right testicular vein? And that's why if you do pick up the right testicle, really, it's important to look for signs of malignancies at that time or not, but you sound and scan the kidneys, so this is an important take a message with regards imaging of mentioned ultrasound already, and that's easy to use. No radiation, thank you know can sufficiently diagnose testicular varicocele. Dilated veins is what you're looking for greater than 2 to 3 millimeters and you could see floor reversal on. But listen Ah, graffiti with valsalva maneuver in a constipation to strain and you can see them. There is a classifications which graced testicle of our conceals on again. It's it's good to know that exists, but usually the diagnosis of a testicle of axial is quite straightforward. Is an example ultrasound imaging dilated and 60 go than it was 33 millimeters. And with a valsalva, you can see his reflux, um, changes there. We don't use it as a primarily matters of diagnosis, but so for the technical issues, guys, I think, um, this man, I myself just got disconnected that and I think we're both back on now. Say, um, his mom will just share his screen again. I'm well, I'm gay. From what? Thank you for your patients. Okay,