Upload
smriti-singh
View
1.538
Download
1
Embed Size (px)
Citation preview
By: Smriti Singh950111095
Urinary Stones are typically
classified by their location as:
NEPHROLITHIASIS (in kidney)
URETEROLITHIASIS ( in ureter)
CYSTOLITHIASIS ( in bladder)
NEPHROLITHIASIS :
A condition marked by the presence of Renal Calculus/ Nephrolith.
Incidence : approxly 2% of population
Peak onset : 20 - 35 years of age
More common in males ( ratio – 2:1)
Etiology/Risk Factors : Infection: By proteus, E.coli,Recurrent UTI,
Diet: Vit A deficiency, Calcium rich diet etc.
Hot Climate . Metabolic causes: Gout, hyperoxaluria etc
Immobilisation.
Others: decreased urinary citrate, stasis, dehydration,sedentary lifestyle etc.
Pathophysiology/ Stone Formation:
Urine Supersaturation
Nucleus Formation
Crystallisation& Aggregation
Matrix Formation
STONE
Types Of Stones:• Hard, single, brown in
colour
• Mulberry stones
Calcium Oxalate stones (75%)
• Smooth, round ,white in colour
• Staghorn calculus
Phosphate stones (10-15%)
• Multiple, yellowish,radioluscent
• Seen in gout etc
Uric acid stones(5%)
• Seen in cystinuria,
• Hard, radio-opaque due to sulphur
Cystinestones (2%)
Clinical Features:
Renal pain
Guarding and Rigidity
Ureteric Colic
Hematuria
Pyuria, Fever
Recurrent UTI
Investigations: Blood and Urine Test
Plain X-ray, KUB
USG
IVP
RGP
CT scan (contrast/ non contrast)
Urine for culture and sensitivity.
Treatment:
• Conservative: Flush Therapy;I.V fluids; Inj frusemide
• ESWL (Extracorporeal Shock Wave Lithotripsy)
Non-Operative
• Endoscopic procedures: PCNL (percutaneousnephrolithotomy)
• Surgical proceduresOperative
ESWL(Extracorporeal Shock Wave Lithotrispy)
Electromagnetic Shock waves are produced.
Dornier Lithotripter is used for fragmenting stones.
Advantages: No anaesthesiaNo incisionNo Pain
Complications: Renal haematomaSevere haematuriaSteinstrasse (stone street)
• Contraindications: PregnancyBleeding disordersAbdominal aneurysm
PCNL (Percutaneous Nephrolithotomy)
Indications:
- Stones not responding to ESWL
- Stones more than 2.5 cm in size- Multiple Stones
Complications:- Haemorrhage- Injury to colon or pluera- Perforation of collecting duct
Steps:
SURGERIES Pyelolithotomy: for
stones in extrarenal pelvis.
Extended Pyelolithotomy.
Nephrolithotomy. Pyelonephrolithotomy. Partial Nephrectomy. Nephrectomy. Coagulum
pyelolithotomy
URETERIC CALCULI:
Always of renal origin.
Stones gets impacted at sites of ureteric narrowing, namely
1. PelviuretericJunction(PUJ)
2. Crossing of the iliac artery
3. Crossing of Vas deferens or broad ligament
4. Site of entry into the bladder
5. Ureteric Orifice
Clinical Features:
Pain –colicky type , radiating- mimics appendicitis,
cholecystitis, ovarian or tubal pathology.
Nausea , Vomiting etc.
Hematuria, dysuria, pyuria etc.
Tenderness in iliac fossa and renal angle.
Complications Of Ureteric Stones:
Obstruction
Hydronephrosis
Infection
Impaction
Ureteral Stricture
• Urine and blood tests
• Plain X-ray, KUB, IVU, CT- scanINVESTIGATIONS
• Conservative: Flush TherapyI.V Fluids, antibiotics, antispadmotic etc
• Surgical InterventionsTREATMENT
Surgical Intervention for UretericStones:INDICATION:
size of stone more than 6-8 mm.IVU showing deterioration of function.Co-existing infection or Impacted stones.
PROCEDURES:For stone in upper third ureter:
ESWL (ideal approach) URS- ureterorenoscopic stone removal Open Ureterolithotomy via loin incision
For Stones in middle third ureter URS
Open Ureterolithotomy
For Stones in lower third ureterURS
DORMIA BASKETING
Open ureterolithotomy
Ureteric meatotomy
Dormia Basketing : Basket is passed into the proximal
ureter beyond the stone and opened and then the stone is pulled out.
INDICATIONS:
stone in lower third ureter.Stone below pelvic brimsingle stone less than 1 cm in size
COMPLICATIONS:
Stone dislodgementurethral injury Avulsion of ureterStricture ureter
Classification
Adenoma: Benign counterpart of RCC
Tumours < 3 cm , rarely metastasize
Angiomyolipoma: Sporadic
Associated with tuberous sclerosis.(50%)
Oncocytoma: Benign,unifocal, 5-8cm average size
Difficult to differentiate from RCC
Wilm’s Tumor (Nephroblastoma)
PathologyGROSS:
smooth, soft,pinkish white in colourwith some haemorrhagic areas.
MICROSCOPICALLY:Mixture of primitive epithelial and
mesenchymal elements.
TYPES:
-FH (favourable histology)- without anaplastic
features.
-UnFH( Unfavourable histology)- with
anaplastic features.
Investigation & Staging Investigation:• Abdomen U/S, CT scan, MRI, X-ray (egg shell)
• IVU
• Renal angiography.
Staging:
Treatment:Unilateral tumours: Nephrectomy and
postoperative radiotherapy .
Bilateral tumours: Partial Nephrectomy
or Nephron Sparing surgery.
Chemotherapy : Actinomysin D,
doxorubicin etc.
Radiotherapy: preoperatively in inoperable
cases followed by surgery and chemo.
RENAL CELL CARCINOMAAlso known as Hypernephroma,
Grawitz tumour, Clear cell carcinoma, Internist tumour.
Most common neoplasm of the kidney.
3% of all adult malignancies.
Arrises from renal tubular cells.
Most common in 5th & 6th decades of life
Male:female ratio- 2:1
Etiology:6 Cs:Chronic cystic disease
Chromosomal defect
Cadmium exposure
Cigarette smoking
Coffee drinking
Congenital disease- (Von Hippel-Lindau disease)
Chronic dialysis & Diabetes are also a risk factor for RCC.
Classification:TYPE INCIDENCE GENETICS MAIN HISTOLOGY
Clear cell carcinoma
75% Familial and sporadic
Well differentiated,clear cytoplasm
Papillary 15% Familial and sporadic
Papillary pattern, psammoma bodies
Chromophobe RCC
5% Multiple chromosome losses, Hypodiploidy
Mixture of pale clear cells with perinuclearhalo and granular cells
Collecting duct of Bellini carcinoma
1% ---- Tubular and papillary pattern
PathologyGROSS:
o Commonly located in upper pole,
o Large, golden yellow, circumscribed
o Cut section- yellowish with areas of haemorrhage & necrosis.
MICROSCOPY:
o Malignant cells are cubical or polyhedral
o Histological types are-clear(75%),granular, spindle, sarcomatoid, papillary(15%)
METASTASIS OF RCCLOCAL: Into perinephric pad of fat,
calyces, renal pelvis.
LYMPHATIC: To hilar L.N, para-aortic L.N
BLOOD :
o To renal vein – as proliferating tumourthrombus
o To lungs – as cannon ball secondaries(50%)
o To bones (30%)
o To liver, brain, adrenal.
STAGING OF RCC
CLINICAL FEATURES OF RCC
Other manifestations include :
Pathological fractures
Anaemia
Hypertension
Liver Dysfustion
Endocrinal disturbances (rare)
Nephrotic Syndrome (rare)
INVESTIGATION:Urine Examination – for RBCs
Plain X-ray KUB
IVP – mass lesion & irregular filling defect.
USG
Contrast enhanced CT scan –Investigation of choice.
Renal angiography
MRI scan- asses the tumour thrombus in IVC
Venacavogram- asses the extent into IVC
Chest X-ray ,CT chest – shows cannon ball secondaries.
TREATMENTRadical Nephrectomy
Radical Nephrectomy with
extraction of tumour thrombus
Nephron sparing surgery
Therapeutic embolisation
Radiotherapy
Immunotherapy –interferon or
interleukin 2