دكتوراه بورد عربي جراحه الكلى بسم الله الرحمن الرحيم Urology Congenital anomalies of the upper urinary tract د.أشرف إبراهيم العدول دكتوراه بورد عربي جراحه الكلى مدرس ـ فرع الجراحة M.B.Ch.B., CABMS(Uro).

Ureteropelvic Junction (UPJ)(PUJ) Obstruction (stenosis) The most common cause of significant dilation of the collecting system in the fetal kidney Boys > Girls Left-sided lesions predominate 15% bilateral ETIOLOGY Intraluminal : mucosal fold that causes valve like effect. Intrinsic (intramural) interruption in the development of the circular musculature of the UPJ Extrinsic An aberrant, accessory, or early-branching lower-pole renal artery

PUJ Obstruction – gross pathology

SYMPTOMS/PRESENTATION Most infants are asymptomatic Most children are discovered because of their symptoms Episodic flank or upper abdominal pain, sometimes associated with nausea and vomiting DIAGNOSIS U/S: hydronephrosis IVU: diagnostic , hydronephrosis with fixed stenotic segment or complete obstruction CT scan: hydronephrosis that ends abruptly Magnetic Resonance Imaging Radionuclide Renography: to see the split function of each kidney Pressure-Flow Studies : Whitaker test

Treatment: Medical: control infection and pain. Surgical: Indications for surgery: 1-progressive hydronephrosis. 2- UTI, and symptomatic patients. 3- Severe hydronephrotic non functioning kidney. 4- Stone formation

Endoscopic Approaches balloon dilatation Antegrade endopyelotomy Treatment SURGICAL REPAIR including open surgical techniques, laparoscopic, & endoscopic approaches Open & laparoscopic surgical techniques Anderson-Hynes dismembered pyeloplasty: excision of the pathologic UPJ & appropriate reanastamosis or flap technique or flap operation Endoscopic Approaches balloon dilatation Antegrade endopyelotomy Nephrectomy for non functioning kidney

Bilateral PUJO

Ectopic Ureters 80% are associated with a duplicated collecting system In the male, the posterior urethra is the most common site of termination, also to semenal vesicle In the female, the urethra and vestibule are the most common sites Clinical features: According to the site of orifice In females: continuous dribbling In males: urinary tract infection Diagnosis IVU, U/S, CT scan, cystoscopy Treatment: Ureteric reimplantation to urinary bladder or implantation of one ureter to the other ureter is used Ectopic ureters may drain renal moieties (either an upper pole or a single-system kidney) that have minimal function. Therefore, upper pole partial nephrectomy (or nephrectomy of single system) is sometimes recommended

Ureteroceles Is due to congenital atresia of the ureteric orifice which causes a cystic dilatation of the intramural portion of the ureter Women > men Sometimes involves with ectopic ureter More prone to stone disease & UTIs Clinical Features : asymptomatic Repeated UTIs, Hematuria Diagnosis IVU, cystoscopy, cystogram The ‘adder head’ on excretory urography is typical. Treatment Asymptomatic : no treatment Cystoscopy with diathermy cauterization of the hole Nephrectomy in non functioning kidney In complicated cases, ureteral reimplantation and vesical reconstruction

Cobra (Adder) head appearance of ureterocele

Ureterocele involving single system Ureterocele involving duplicated ureter

Congenital Megaureter Grossly dilated ureter Unilateral or bilateral More common in male Clinical features: Asymptomatic, pain, repeated UTIs lower ureter might be obstructed sometimes associated with vesicoureteral reflux Diagnosis : IVU

Treatment Infection should be controlled Excision of the lower stenotic segment (if present) Ureteric tapering & reimplantation in to the bladder Nephroureterectomy for non functioning kidney

Postcaval (Retrocaval) ureter (Preureteral Vena Cava ) The right ureter pass behind the inferior vena cava This might causes obstruction It is a vascular abnormality Incidence: about 1 in 1500 Although it is congenital, most patients present at 3rd or 4th decade. Diagnosis: IVU Treatment surgical correction involves ureteral division, with relocation and ureteroureteral or ureteropelvic reanastomosis, usually with excision or bypass of the retrocaval segment, which can be aperistaltic

Renal surgical infections

Renal surgical infections Urinary tract infection (UTI) is an inflammatory response of the urothelium to usually bacterial invasion that is usually associated with bacteriuria and pyuria. Classification Non specific Specific ( T.B. & Bilharziasis ) Acute Chronic

Non specific acute infection Bacteriology: E.coli ( most common) Proteous, Staph aurious, Klebsiella Pathogenesis: Ascending infection: most common route Hematogenic Lymphatic Direct extension

Susceptibility Bacterial virulence Extrinsic factors : male & female Introitus Urethra Prepuce Intrinsic factors: Bladder, ureteral & renal

Bacterial persistence Urinary calculi Obstructive uropathy Renal pathology Urethral infection Foreign bodies Urogenital & intestinal fistulae

Kidney Infections Acute pyelonephritis Clinical features: Defined as inflammation of the kidney and renal pelvis It is a clinical syndrome of chills, fever, and flank pain that is accompanied by bacteruria and pyuria, a combination that is reasonably specific for an acute bacterial infection of the kidney. Female > male Clinical features: Constitutional symptoms Flank & hypochondrial pain Frequency, urgency, & dysuria

Investigations GUE Urine +/- blood culture & sensitivity U/S KUB IVU

Treatment Depends on the severity of the infection Admission to the hospital, Bed rest Parenteral broad spectrum antibiotics until results of C&S Analgesics Encouraged copious fluid intake otherwise give IVF N.B. obstructive Pyelonephritis needs drainage

Pyonephrosis Pyonephrosis refers to infected hydronephrosis where the kidney is converted into a sac containing pus associated with suppurative destruction of the parenchyma of the kidney, in which there is total or nearly total loss of renal function. It is usually unilateral Causes Infected hydronephrosis Following acute pyelonephritis Complication of renal calculus disease

Investigations CLINICAL FEATURES The patient is usually very ill Flank pain & Tenderness High fever ,chills Anaemia Investigations GUE + C&S + blood C&S CBC KUB U/S IVU CT scan

Treatment It is Surgical Emergency that needs drainage Parenteral antibiotics Drainage of the kidney ..nephrostomy: --percutaneous -- open .. JJ stint The stone is removed nephrectomy

Renal Abscess or Renal Carbuncle Renal abscess or carbuncle is a collection of purulent material confined to the renal parenchyma. The renal parenchyma contains an encapsulated necrotic mass Insidious onset (may run > 2 weeks) Obscure fever Local pain Symptoms of the primary cause Tender renal angle Tender mass : differentiate from malignant lesion

Bacteriology Hematogenic infection Commonly coliforms & staph aureous, proteous, klebsiella. Predisposing factors Diabetic patients I.V drug therapy Hemodialysis Immunocompromized Skin infection Rarely ascending infection

Clinical picture Usually underlying pathology: systemic bacterial infection, skin infections, urinary stones, vesicoureteric reflux, obstruction, DM Infection—liquefaction—abscess formation Male : female 3:1 Age : 20---30 year Loin Pain Fever On exam.: renal angle tenderness

Investigations GUE ???? Urine C&S ???? Blood culture ???? U/S KUB, IVU WBC:Leuckocytosis U/S KUB, IVU CT scan

Surgical: Abscess drainage Treatment Medical: Rest Analgesia Antibiotics Follow up examination Surgical: Abscess drainage Nephrectomy

Perinephric Abscess Route of infection: Rupture of renal abscess Infected perinephric hematoma or urinoma Extension from nearby organs: Appendix, Gall Bladder, Pelvic organs. Hematogenic: Tonsillitis, boils etc.

Bacteriology Ecoli Staph aureous Proteous Klebseilla

Pathology Cortical abscess coallese, enlarge, rupture to the perinephric space, form a perinephric abscess Fluid filled inflammatory mass Thick wall, adhesions.

Clinical picture Fever , rigor Dysuria, frequency Renal tenderness Visible loin mass, tender, +ve fluctuation

Investigations Leucocytosis, Anemia Pyurea, +ve bacterial culture U/S CT scan KUB : soft tissue mass, stones. IVU , Tomography Chest x ray : ? Reactionary pleural effusion

Treatment Bed rest Antibiotics & analgesics Always combined with drainage: Under U/S or CT- scan guidance Open drainage

Chronic non specific infection Xanthogranulomatous Pyelonephritis Rare, severe, chronic renal infection typically resulting in diffuse renal destruction. Commonly affect middle age Mixed bacteria: E. coli, Proteous mirabilis Predisposing factors: Diabetic Renal stone disease Neurogenic uropathy Obstructive uropathy

Macroscopic appearance: Excessive fatty infiltration, Xanthene deposit Clinical picture Chronic Loin pain Low grade fever & malaise Weight loss Renal mass Multiple fistulae Macroscopic appearance: Excessive fatty infiltration, Xanthene deposit

Investigations GUE KFT U/S CT scan KUB IVU

Treatment Always surgery… Nephrectomy Under antibiotic cover

prostatitis Acute prostatitis Bacteria: E. coli, staph aureus, S. faecalis, N. gonorrhoea Route of infection: -Hematogenous -2ry to UTI

Clinical features Fever, shivering , rigor Backache, perineal pain Irritative voiding symptoms: dysuria, frequency Obstructive urinary symptoms Pain on defecation O/E: DRE : enlarged, extremely tender, hot, soft prostate

Treatment Admission ? Bed rest Analgesics Antipyretics Parenteral antibiotics If abscess: drainage If retention: suprapubic catheterization.

Specific infections of the urinary tract Renal Tuberculosis Bacteria: Mycobacterium TB Pathogenesis: Hematogenic Start unilateral , late bilateral affection. The 1st lesion starts usually in the pyramids Chronic: Asymptomatic until late stage TB granuloma, caseation, open to the calyces. Renal destruction, calcification. The ureteric upper & lower 1/3rd is affected Ureteral & bladder involvement is commonly secondary to renal T.B.

Clinical picture Always suspect if: Endemic area Age : 20-30 year Male : female 2:1 Chronic symptoms Non responsive UTI to adequate therapy. Unexplained hematuria. loin pain

Night sweating, Wt loss Fever when secondary bacterial infection Chronic renal sinuses. TB is the most common opportunistic infection in AIDS patients

Investigations GUE : RBC , Sterile acid pyuria. -ve urine C&S Three successive morning urine samples for AFB. 24 hours urine collection for AFB. TB culture & sensitivity. ESR WBC total & differential. KUB: Renal calcification IVU CXR Cystoscopy: for lower tract involvement.

Treatment Medical: Surgical: If complicated No clinical control Correct obstruction Nephrectomy.

Complications Perinephric abscess Pyonephrosis Renal stones Ureteral strictures Renal cutaneous sinuses Chronic renal failure. Autonephrectomy in ureteral obstruction Bladder contracture (thimble bladder)

Bilharziasis Trematode: schistosoma haematobium Male: female 3:1 Endemic in Nile valley, Iraq, & middle east in general. Marshes & slow running fresh water is the habitat of the fresh water snail ( bulinus truncatus ) which is the intermediate host.

Mode of infestation The bifid tailed embryos (cercariae) penetrate the skin, enter the blood vessels, flourish in the liver, develop into male & female worms, they pass to the vesical venous plexus The female pass to the submucous venule to lay its eggs with its terminal spine which penetrate the vessel wall & pass with urine & if reach fresh water it penetrates the intermediate host.

Clinical features Urticaria ( swimming itch ) Fever , sweating Hematuria: intermittent, terminal Lymphadenopathy & splenomegaly

Investigations GUE : early morning samples for several consecutive days – ovae with terminal spines Leukocytosis – eosinophilia Cystoscopy Bilharzial pseudotubercles , nodules, sandy patches, ulceration, fibrosis, granulomas, papillomas, carcinoma (SCC).

Imaging study KUB U/S

IVU

Treatment Antimony e.g. praziquantel & metriphonate Papilloma : endoscopic removal Carcinoma : radical cystectomy

Complications 2ry bacterial infection Vesical & ureteric calculus formation Terminal ureteric stricture : needs dilatation or ureteric reimplantation Prostatoseminal vesiculitis Fibrosis of the bladder & bladder neck Urethral stricture & fistula formation. Thank you