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RENAL

• Most common Congenital anomaly seen in


upper renal tract
– Duplication of Renal Pelvis
• Most common renal vascular anomaly
– Supernumerary Renal Arteries
• Left Renal vein. The left renal vein courses
between the aorta and superior mesenteric
artery to join the inferior vena cava. The left
renal vein passes in front of Aorta.
The left gonadal vein will drain into to left
renal vein. The right gonadal vein drains
dnirectly into the inferior venal cava
Renal Cell Carcinoma/Hypernephroma/Grawitz Tumor
• Classic triad of Pain, Hematuria and Flank mass
• Chromophobe Variants of Renal Cell Carcinoma are characterised
by widespread/extensive chromosomal loss resulting in monosomy
or hypodiploid DNA index
• Highly Vascular Tumor may pulsate, SOLITARY PULSATILE BONE
SECONDARIES
• Associated with left sided Varicocele
• Associated with Von Hippel Lindau Disease
• Often Swept into circulation and ends up in the lungs forming canon
ball secondaries
• Associated with Paraneoplastic syndromes
(Erythropoietin(Polycythemia), ACTH(Cushing Syndrome),
PTHrP(Hypercalcemia), Renin(Hypertension))
• The most common sites of metastasis are, in order: the lungs, the
bones, lymph nodes, the liver, adrenals and the brain
Treatment of Renal Cell Carcinoma
• Tumor </= 4cm: Partial Nephrectomy
• Tumors 4-7 cm: Partial or Radical
Nephrectomy
• Tumors > 7 cm: Radical Nephrectomy
Renal tuberculosis/ Tuberculous
Pyelonephritis
• Arises from hematogenous Spread
• Frequency is the earliest and the only
symptoms
• STERILE PYURIA IN ACIDIC URINE
Renal Stone
• Most common Stone: Calcium stone, Treatment:
Thiazides
• Magnesium Ammonium Phosphate (Struvite)
calculi associated with urea splitting bacterial UTI,
usually proteus mirabilis, Staghorn
Calculus(Phosphate Stone)
• 90% of renal stone are radio opaque
• RadiolUCent: Uric Acid Stone, Cysteine
• Hard stones like Cysteine and Calcium oxalate
monohydrate are difficult to be broken by ESWL
Renal Trauma
• Hematuria is the cardinal sign of renal damage.
• An intravenous urogram (IVP) should be done
urgently to demonstrate that the other kidney is
normal.
• Investigation of choice in Renal Trauma is CT Scan
• Conservative treatment is successful in most of
the cases.
• Aneurysm of the renal artery is a rare
complication of renal trauma and its most
frequent symptom is pain in the renal region
Horse Shoe Kidney
• In this disorder, the patient's kidneys fuse together to
form a horseshoe-shape during development in the
womb. The fused part is the isthmus of the horseshoe
kidney
• Infection, tuberculosis and stone formation are
common complication
• Urogram shows lower pole calyces on both sides being
directed toward the midline
• Ureters characterstically show flower vase like curves
• Horse Shoe Kidney is not a contraindication to
pregnancy
• Association can be with VUR, Turner Syndrome
Ureterocele

• Congenital atresia of the ureteric orifice


resulting in cystic dilatation of ureter
• On Excreting Ureterogram: Cobra Head/Adder
Head Appearence
Bladder carcinoma
• Most common type: Transitional Cell Carcinoma
• Most common site: Trigone >> Lateral Wall
• Most presenting symptoms: Painless Hematuria
• Etiological agents: Aniline dyes, Cyclophosphamide, Schistosoma
Hematobium(Squamous Cell), Smoking
• Investigation: The investigation of choice to establish bladder carcinoma is
Cystoscopy, Urinary cytology for bladder urothelial cancer cells remains
the standard non-invasive screening test
• Urine Exofolative Cytology is most sensitive to detect high Grade
Transitional Cell Carcinoma of Urinary Bladder
• No Role of Urine tumor markers

Tuberculous Cystitis: Thimble Bladder


Thimble bladder is a descrip ve term for extreme brosis and contracture of
the bladder walls, resulting in a tiny bladder
• Recommended Investigations in individual
>40yrs old who develop hematuria
– Urine Cytology for malignant cell
– Cystoscopy Imaging Of Urinary tect with IVP/CT
Scan
Exostrophy of Bladder/Ectopic Vesicae
• Incomplete development of infraumbilical part of
anterior abdominal wall associated with incomplete
develpment of anterior wall of bladder owing to
delayed rupture of cloacal membrane
• Since ant.abdominal wall is absent, the posterior
bladder wall through the defect
• Association
– In male: Complete Epispadiasis, B/L Inguinal
– In Female: Clitoris Bifid
• Repair of the Bladder soon after delivery is desirable
• Urine Exofolative Cytology is most sensitive to
detect
– High Grade Transitional Cell Carcinoma of Urinary
Bladder

• Painless gross hematuria


– Urinary Bladder Ca
– Renal Cell Carcinoma

• Most common site of rupture of urinary bladder


– Extraperitoneal

• Most common cause of bladder rupture is


– Pelvic trauma
Urethra
• Prostatic Part: 3 cm, widest and most dilated
part. Urethral Crest (Verumontanum) is a
median longitudnal ridge of mucous
membrane. Most common site of opening in a
case of duplication of Ureter
• Membranous Part: 1.5 – 2 cm, shortest part
• Spongy Urethra(Penile): 15 cm, bulbourethral
glands opens in penile urethra
• Most common site of Urethral Carcinoma is
– Bulbomembranous Urethra

• Most common site of postgonoccal stricture


– Bulbar Urethra
Urethral Rupture
• Rupture of Bulbar URETHRA is more common
• Rupture of Bulbous Urethra and Rupture of
Membranous Urethra (Intrapelvic Urethra)
• Triad of Rupture bulbar Urethra is Retention of
Urine, Urethral Haemorrhage, Perineal
Hematoma (@PURE)
• Most common cause of rupture of
Membranous(Intrapelvic) Urethra is Pelvic
fracture
• NOT TO BE DONE: Intraurethral Cathetrization
Posterior Urethral Valve
• Symmetrical folds of Urothelium
• Common distal to Verumontanum
• Occur in Males Only
• Most common cause of Urinary Retention in
Male Infant
• Diagnosed by VCUG
Ureteropelvic Juction Obstruction
• Most common obstructive lesion in childhood
• Presentation
– Hydronephrosis Revealed by Maternal USG
– Palpable Renal Mass in Newborn/Infants
– Abdominal flank r back pain
– UTI/Hematuria
• Management
– Nuclear Renography to determine Renal Differential fucntion
– Conservative Management if differential function of >40%
– Differential function of <40% is considered significant and often
an indication for surgical management (Pyeloplasty)
• Differential Function of < 10% is often considered as
arbitary cut off for nephrectomy
Penis
• Lymphatic from glans penis drain into deep
inguinal lymph nodes (glans of cloquet)
• Premalignant lesion of Sq. Cell Carcinoma
– Bowen Disease
– Erythroplakia of Queryet
• Causative Organism
– HPV 16 and 18
Phimosis
• Phimosis is a condition in which the foreskin
can't be retracted (pulled back) from around
the tip of the penis
• Result in ballooning of skin or recurrent
balanitis
• Treatment: Circumcission

• Best Treatment of a case of Paraphimosis:


Dorsal Slit
Priapism
• Painful Erection of Penis
• May be associated with
– Sickle Cell Anemia or Trauma
– Trazodone, an antidepressant
• Surgical management of ischaemic priapism
includes surgical creation of shunt or fistula
– Corporoglandular Shunt
– Corporo-spongiosal Shunt
– Corporo-saphenous Shunt: Grayhack Shunt
– Corporo-dorsal vein Shunt
Peyronie’S Disease
• Chronic Inflammation of Tunica Albuginea is a
connective tissue disorder involvin the groeth
of fibrous plaque in the soft tissue of the penis
• Pain, abnormal curvature, erectile dysfunction
Hypospadiasis
• Most common congenital malformation of urethra
• External urinary meatus is situated at some point on
undersurface of penis or the perineum
• Most common type: Glandular variety
• Perineal Variety is most severe
• Chordee (Downward curvation of penis)
• Inferior aspect of prepuce is poorly developed (Hooded
Prepuce)
• No treatment is required for glandular variety
• Circumcision shouldnot be done in Infancy

• Ideal Age for repair of Hypospadiasis 6-10 month


Pyonephrosis

• Kidney is converted into a multilocular sac containing


purulent urine or pus with varying amount of renal
parenchyma in its walls
• Results from infection of a hydronephrosis or follow an
episode of acute pyelonephritis
• Most commonly it is a complication of renal calculus
• Classical triad of pyonephrosis consists of: Fever, Loin
swelling, Anemia
• As a rule pyonephrosis is always Unilateral
• Subcapsular Nephrectomy is indicated
Hydronephrosis Association
• Prune Belly Syndrome (Eagle Barret Syndrome)
• Dietls Crisis

• Dietel Crisis
– Feature of Unilateral, Intermittent Hydronephrosis
– After an attack of acute renal pain, a swelling in the
loin is found. Some hour later, following the passage
of urine pain is relieved and swelling dissapears
Hydronephrosis Association
• Prune Belly Syndrome (Eagle Barret Syndrome)
• Dietls Crisis

• Dietel Crisis
– Feature of Unilateral, Intermittent Hydronephrosis
– After an attack of acute renal pain, a swelling in the
loin is found. Some hour later, following the passage
of urine pain is relieved and swelling dissapears
Prune Belly Syndrome
• Fascia of Denonvilliers
– The posterior surface of the prostate gland is
separated from the rectum by fascia of
Denonvilliers
Different zones of prostate gland
• Peripheral zone (PZ) which lies mainly posteriorly
and most carcinomas arise from this zone. This is
the reason; we have to palpate the prostate from
the rectum to find the hard prostate to rule out
carcinoma.
• Central zone
• Periurethral transitional zone from which most
benign prostatic hyperplasia (BPH) arises
• NOTE: BPH results in obstruction of urinary tract.
The specific condition is associated with
enlargement of the Median lobe
Drugs used for BPH
• Alpha 1 adrenergic blocking agent: Prazosin,
Terazosin, Tamsulosin
• 5-alpha reductase inhibitor inhibits conversion
of testosterone to dihydrotestosterone, e.g.
Finasteride
• Antiandrogen may help men with significantly
enlarged prostates. e.g. Flutamide
TURP
• The verumontanum is the single most important
anatomical landmark in TURP.
• The verumontanum lies immediately proximal to the
external sphincter muscle and serves as the distal landmark
for prostate resection to prevent injury to the external
sphincter.
• Hyponatremia is avoided by using 1.5% isotonic glycerin for
irrigation. (Distilled Water is never used for irrigation)
• Absorption of water into circulation at the time of TURP
(water intoxication) can give rise to CHF, hyponatremia, and
hemolysis which may manifest as confusion and other
cerebral events mimicking a stroke.
• Post TURP first complication Vomiting
• Most common complication: Retrograde Ejaculation
Indications of prostatectomy in BPH
• Acute retention- BPH is the most common cause
of urinary retention in elderly males.
• Chronic retention and renal impairment:
Residual urine of 200 ml or more, a raised blood
urea, hydroureter or hydronephrosis demons-
trated on urography and uremic manifestations.
• Complications of bladder outflow obstruction:
stone, infection and diverticulum formation.
• Hemorrhage
• Most common site of obstruction after TURP is
– Bladder Neck

• Laser used in treatment of BPH


- Nd:YAG

• During TURP, Surgeon takes care to dissect above


the vermontonum to prevent injury to
– External Urethral Sphincter
Marion Disease
• Obstruction to the neck of bladder
• Treatment consists of opening the bladder and
performing Y-V plasty
VaricoceLE
• Abnormal enlargement of veins in the scrotum draining
the testicles
• 98% occur in left side, apparently because the left
testicular vein runs vertically upto the renal vein, while
the right testicular vein drains directly into inferior
venecava
• Variocele may be the indicator of left renal tumor
• Heavy, Dragging aching sensation in scrotal
compartment
• May be like Bag of Worms
• Embolisation of gonadol vein is the first line
intervention
Prostratic cancer
• Low Back Pain and Retention of Urine
• Raised Value of ACID PHOSPHATASE
• Most Specific is Prostrate specfic antigen.
• Prostratic Carcinoma most commonly arises from Peripheral
Zone,
• Most common site of metastasis is Pelvic Bones
• Bone Metastasis in the prostrate is Osteoblastic
(Osteosclerotic)
• Metastasis to vertebrae is through Bateson vertebral venous
plexus
• Gleason staging is done for prostratic carcinoma
• NOTE: BPH arises from Periurethral transitional zone, BPH is
the most common cause of urinary retention in elderly male
Most Specific Screening Protocol for
Prostate Ca (Purely Osteoblastic)
• DRE + PSA
• The raised value of aCid phosphatase is highly
suggestive of prostate Cancer
Carcinoma of prostate metastasize

• Valveless communication exists between the


prostatic and vertebral venous plexuses
through which prostatic carcinoma can
spread.
• Spread by blood stream occurs particularly to
bones. The bones involved most frequently by
metastasis of prostatic carcinoma are the
pelvic bones.
Treatment of Prostate cancer

• Treatment is controversial, as many cases of


prostate cancer are slow to progress. Treatment
choice is based on the aggressiveness of the
tumor and the patient’s mortality risk.
• Watchful waiting may be the best approach for
elderly patients with low grade tumors.
• Radical prostatectomy and radiation therapy
(e.g. brachytherapy or external beam) are
associated with increased risk of incontinence
and/or impotence.
Feature of Typical Semen Specimen
• Total Volumne: 3-5 ml
• Sperm Count: 60-120 million
• Motility: 80%
• Morphology: 80% or more normal
• Pus cell Should be absent
• OLIGOSPERMIA: < 20million/ml
• AZOOSPERMIA: Absence of sperm

• Teratozoospermia
– Presence of high number of malformed spermatozoa in
the semen
Common tumor of Testis
• Seminoma (MC overall, Yolk sac tumor is MC in children,
Lymphoma is elderly)
• Teratoma
• Combined Seminoma and teratoma
• Lymphoma
• Interstitial tumor

• Note: Commonest site for testicular tumor metastasis is


Lungs
• Diagnosis of testicular cancer is made by performing a
radical orchidectomy by a inguinal route, Irreversible drastic
step is justified because testicular tumor are never beningn
Seminoma

• Seminoma is most common tumor of testes both


on descended and undescended.
• Cut surface homogenous
• Secrete Beta HCG
• Cyptoorchidism is a risk factor for seminoma
• Corresponds to Dysgerminoma of Ovary in
females (Dysgerminoma usually secrete PLAP and
LDH,,,, Beta HCG in few cases)
• Extremely Radiosensitive, Excellent Prognosis
• Seminomatous – radiosensitive late
metastasis, excellent prognosis
• Non seminomatous – not radiosensitive, early
metastasis, more aggressive

• Note: Hemorrhage and necrosis in tumor


suggests aggressive tumor, not Seminoma
• Surgery for undescended testis is recommened at
which age
– 6 months
• Surgery for undescended testis should be
performed before
– 12 month
• Orchidopexy should not be performed before 6
months of age, as testes may descend
spontaneously during the first few months of life.
AFP
• Non seminomatous GCT (Yolk sac
tumor/Endodermal Sinus tumor, Embryonal
Carcinoma, Teratoma)
• Hepatocellular Ca/Hepatoblastoma: Maxm
raised
• GI Carcinoma e.g: Ca. Colon
• Ca lung
• Non Neoplastic Condition (Cirrhosis, Hepatitis,
Pregnancy)
Testicular Torsion vs Epididymitis
• Pain stay same/worsen with testicular
elevation in Testicular torsion where as in
Epididymitis Pain decreases with elevation
• Immediate Surgical Intervention is indicated in
testicular torsion as it is an medical
emergency
PCKD
• ARPCKD
– Present in infancy
– Renal Hepatic Disease
– Evidence of Liver Disease is seen in 45% of cases
• ADPCKD
– Adult are Dominant So Autosomal Dominant
– Chromosome a/w ADPKD 16 & 14
– Cyst in liver (MC Site), pancreas, spleen and ovaries
– Intracranial Anuerysm 15%
– Mitral Valve Prolapse 12%
– Renal Cell Ca
– HTN
– Spider Leg Appearance is seen in Excretory Urography
• Medullary Sponge Kidney
– Congenital disorder characterised by cystic dilatation of inner medullary and papillary
collecting duct
– Cyindrical dilatation of renal tubules occur
– Associated with Nephrocalcinosis
– Best Diagnosed by Biopsy
Renal Papillary Necrosis
• Necrosis of all or part of the papilla of renal
pyramid
• Causes
– Bacterial Nephritis
– Analgesic Overuse (Phenacetin, Acetaminophen)
– Diabetes Mellitus
– Sickle Cell Disease
– Vascular Disease
– Tuberculosis
Renal Investigation
• MCUG/VCUG
• DTPA: Physiology (Function) of the Kidney
• DMSA: Stucture (Anatomy) of the Kidney