Surgery

L5- Diseases of the

kidney and ureter – P2
Prof. Mahmood Sh.A.Karbalaie
F.R.C.S.,F.I.C.S.,F.I.CM.S
Consultant urologist

Illustration by Smart-Servier Medical Art

1. Classification, definitions, pathogenesis, and management of urinary
tract infections.

2. classify and describe the different types of benign and malignant

tumors of the kidney.

learning
objectives
Illustration by Smart-Servier Medical Art
 Congenital cystic kidney
• Autosomal dominant
• Abdominal mass
• Haematurea
• Infection
• Hypertension
• Uraemia
• Conservative vs transplant
Hydronephrosis

• It is an aseptic dilitation of the PCS of the kidney due to back pressure

by either obstruction or megaureter or reflux effect

• It could be uni or bilateral

Causes:
• Stone
• Tumors
• Inflammatory stricture
• Infection TB, bilharziasis
• PUJ obstruction
• reflux or Uretrocele
• Obstruction of the ureter from outside, tumor fibrosis
• For bilateral hydro, urethral stricture, BPH, meatal stenosis
Clinical features Diagnosis

• Asymptomatic • Urine exam

• Urine C&S
• Pain dull or colic • Ultrasound
• Swelling of the loin • IVU,CT,MRI
• Abscess formation • Radioisotop scan DTPA ,DMSA,MAG3
• Renal failure if bilateral • Endoscopy
• Pressure test
‫للتوضيح ‪:‬‬
Vesicoureteric reflux
• An etiology in 9% of individuals with hydronephrosis.
• Predisposes individuals to chronic renal failure.
• Best evaluated by voiding cysturethrogram (VCUG)

Grade I- Ureter only

Grade II - Ureter, renal pelvis, calyces without dilatation
Grade III - Dilatation or tortuosity of ureter and/or dilated pelvis
Grade IV - Shape of calyces maintained but dilated.
Grade V - Gross dilation of collecting system

Management may include prophylactic antibiotics or surgical intervention

Treatment
• Pyloplasty
• Reimplantation
• Prostatectomy
• Urethrotomy
• Catheter drainage JJ cath, nephrostomy, urethral cath
Kidney infection

• bacteria reach the kidney either from the blood or from the lower part of
the urinary system.

• Common organisms include E.coli, Gram negative or Proteus

• More in females
• Progress to septicaemia
• Acute pyelonephritis, common type of kidney infection
Presentation Investigation
• Fever •Midstream urine sample
• Pain •Culture and senstivity
•Ultrasound
• Headache
•Renal function test
• Nausea •Blood culture
• Urgency •Cystoscope
• Frequency •Contrast study
• Dysurea
• uraemia
Treatment
• According to C and S antibiotic is
given eg. Amoxicillin and gentamycin

• Treat the cause

Chronic pyelonephritis

• Intestinal inflammation and scaring

• Pyonephrosis is a hydronephrosed infected kidney
• Renal carbuncle abscess formation in the kidney parenchyma
• Perinephric abscess
 Infections
• UTI is very common and affects all ages and both sexes.

• It can cause significant morbidity and is a rare cause of mortality in patients with serious
comorbidities or in patients with urinary tract obstruction.

• Recurrent UTI is more common in women, affecting 30–40% in the sexually active age group.

• It can be defined as an inflammatory response of the urothelium (host) to invading bacteria.

• Asymptomatic colonization or bacteriuria is also common and can be from a UTI by the
absence of symptoms and pyuria (leukocytes in urine).
Classification
• UTI is classified as uncomplicated when it occurs in an immunocompetent host with an
anatomically normal and functional urinary tract.

• UTIs may also be classified on their site of origin as pyelonephritis (kidney), cystitis (bladder),
urethritis or prostatitis.

• While acute pyelonephritis indicates an acute infection of the kidney, chronic pyelonephritis is
only a morphological description of previous infection-related sequelae such as scarring in the
kidney as seen on radiological or nuclear imaging.
Acute pyelonephritis
• This commonly occurs as a result of ascending infection from
organisms in the lower tract, usually caused by Gram-negative
bacteria.

• Hematogenous spread may be seen in patients with diabetes

and in immunocompromised hosts, people who inject drugs and
patients with bacterial endocarditis.

• It is more common in females, especially during childhood, at

puberty, after intercourse and during pregnancy.

• Acute pyelonephritis usually presents with fever, chills, flank

pain, nausea and vomiting . Loin tenderness may be present.
Symptoms :
• may vary from mild to severe illness with septic shock and renal failure.
• Pyuria is almost always present and its absence in a patient with pyelonephritis may point
towards an obstructed urinary tract.
• Urine and blood should be collected for culture.
• Escherichia coli and other Gram-negative organisms are commonly responsible.
Imaging
• is necessary when the patient is not responding to antibiotics to rule out pyonephrosis, renal
abscess and obstruction. Renal US is often the first imaging modality used.
• Contrast-enhanced CT (CECT) typically shows decreased patchy opacification of the affected
parenchyma.
Pyelonephritis complicating pregnancy :
• The relaxing effect of progesterone during pregnancy causes ureteral smooth muscle relaxation
and dilatation, presumably predisposing pregnant women to ascending upper tract infections.

• It is associated with fetal growth retardation and preterm delivery. Therefore, all pregnant women
must be screened in the first trimester for ABU because, untreated, a third of these patients will
develop UTI.

• Lower tract UTI typically occurs in the first trimester whereas pyelonephritis most often presents
in the second or third trimester with acute abdominal pain or premature labor.

• Pyelonephritis is more common in pregnant women with an underlying urological abnormality or

diabetes.

• A renal US is indicated if response to treatment is poor.

• Antibiotic use during pregnancy is tailored to avoid fetal harm and typically includes fosfomycin,
penicillin’s or cephalosporins
Renal and perirenal abscess
• A renal abscess results from an ascending UTI in association with an underlying urinary tract
abnormality such as obstructive uropathy or VUR.

• It is usually caused by common uropathogens such as E. coli and other Gram-negative bacilli.

• Renal abscesses may extend and perforate the renal capsule to form a perirenal abscess.

• Multiple renal abscesses may conglomerate into a solitary suppurative lesion called a renal
carbuncle. This is usually caused by Staphylococcus aureus, which reaches the kidney by
hematogenous spread.
• The clinical presentation may be insidious and non-specifc but patients usually present with
persistent fever, back pain, abdominal pain and costovertebral tenderness.

• Urine examination may be normal if the abscess does not communicate with the collecting
system.

• CECT scan is the investigation of choice to establish the diagnosis.

• Treatment with antibiotics without drainage may be effective in carefully selected patients
when the abscess is small (5 cm and in patients not responding to antibiotics. Open surgical
drainage is indicated when percutaneous drainage is inadequate.
Emphysematous pyelonephritis
• This is an acute-onset, rapidly progressive, possibly lethal form of pyelonephritis characterized
by parenchymal necrosis and gas formation, caused by organisms including E. coli, Klebsiella
pneumoniae, Pseudomonas aeruginosa and Proteus mirabilis.

• Most patients have diabetes (up to 90%) and they may have obstruction secondary to calculi or
papillary necrosis.

• Increased glucose levels in those with diabetes may provide a substrate for carbon dioxide
production from fermentation.
• Symptoms are suggestive of pyelonephritis and an abdominal mass may be palpable.

• CECT of the abdomen is diagnostic and shows gas in the renal parenchyma, collecting system
or both, along with other features of infection such as abscess, obstruction and perinephric
stranding.

• Early diagnosis, intravenous broad-spectrum antibiotics and percutaneous drainage of the

abscess and obstructed kidneys have improved outcomes in these patients.

• Emergency nephrectomy is rarely required and is reserved for patients who do not respond to
the described measures.
Xanthogranulomatous pyelonephritis
• Xanthogranulomatous pyelonephritis (XGP) occurs with severe renal infection in an
obstructed kidney and is usually associated with calculi, causing loss of function and
parenchymal destruction.

• Pathological examination typically shows accumulation of lipid-laden foamy macrophages.

• Patients may present with flank pain, fever with chills, persistent bacteriuria and a flank mass.

• A history of stone disease may be present. It is usually unilateral.

• CECT of the abdomen is diagnostic and shows a non-functioning enlarged hydronephrotic

kidney around a shrunken pelvis with a calculus, also known as the bear’s paw sign .

• Nephrectomy is the definitive treatment.

Tuberculosis of the urinary tract
• Genitourinary tuberculosis (GUTB) accounts for 15–20% of extrapulmonary cases of TB.

• It is secondary and caused by hematogenous spread of tubercle bacilli from the thoracic lymph
nodes or the lungs.

• GUTB occurs as a result of either reinfection or reactivation of old TB granulomas.

• Blood-borne organisms are deposited close to the glomeruli, causing an inflammatory

reaction.

• Macrophages react and granulomas are formed. If bacterial multiplication goes unchecked,
caseous necrosis results in the formation of tubercles.

• Multiple tubercles coalesce and rupture into the collecting system, causing intermittent
tuberculous bacilluria and pyuria.
• The disease spreads through the collecting system with ulceration initially.

• When bacterial multiplication is halted by the immune system, sequelae due to fibrosis
appear.

• Tubercular obstructing or destructive lesions in the kidneys and ureters are responsible for
renal function loss.

• Involvement of the bladder is secondary to renal disease.

• The disease gradually involves the bladder musculature, which is replaced by fibrous tissue,
causing a decrease in the size and capacity of the bladder (‘thimble’ bladder).

• Urinary bladder involvement is responsible for urinary frequency, which is the most common
symptom of GUTB.

• Epididymal tuberculosis presents as a painless epididymal nodule, usually involving the tail of
the epididymis, or a chronic discharging sinus in the posterior scrotal wall
• Patients may present with urinary frequency, colicky flank pain, hematuria and, rarely, fever and
constitutional symptoms.

• They may also present with symptoms suggestive of recurrent UTIs and, rarely, calcified
tubercular lesions may be misdiagnosed as urinary tract calculi.

• For microbiological confirmation, at least three consecutive earlymorning specimens of urine are
examined for acid-fast bacilli.
• The gold standard for microbiological diagnosis is urine culture.

• Nucleic acid amplification tests (NAATs) provide rapid diagnosis (within hours).
• When the diagnosis remains uncertain, bladder biopsy, tissue culture and tissue NAATs may be
required.

• Imaging with CTU may also help and can show early signs such as calyceal distortion and
papillary necrosis, hydronephrosis, poor function of renal segments secondary to parenchymal
destruction, fibrosis and chronic obstruction.
• Ureteric strictures and proximal dilatation may also be seen.
• IVU can pick up the earliest signs of disease activity, such as calyceal distortion
• Treatment involves short-course antituberculous therapy (ATT). Rifampicin, isoniazid and
pyrazinamide are used sometimes with ethambutol as first-line drugs.

• The primary aim of therapy is preservation of renal function and avoidance of fibrotic sequelae.

• Ureteric strictures may require double J (DJ) stenting to preserve function until definitive
reconstruction is attempted.

• Percutaneous nephrostomy (PCN) is recommended in obliterative strictures to achieve prompt

decompression.

• Definitive surgery is usually done 3–6 weeks after starting ATT.

• The choice of reconstructive procedure depends on the type and location of sequelae.

• Open surgical repair is generally superior to balloon dilatation for tubercular ureteric strictures.
• Augmentation enterocystoplasty (usually using ileum) for small-capacity bladder ureteric
reimplantation with or without a Boari fap (bladder tube) for lower ureteric stricture and ileal
replacement of the ureter for multiple long ureteric strictures may be required.

• Nephrectomy is done for major renal lesions with a poorly functioning kidney.

• Urinary infection in childhood and vesicoureteric reflux All children with UTI must be evaluated
for underlying predisposing conditions as recurrent pyelonephritis can cause renal scarring and
loss of renal function.

• UTIs account for 7% of childhood febrile illness. In the age group 1 year, it is more common in
females.

• Structural and functional abnormalities of the urinary tract such as VUR and posterior urethral
valves predispose to UTI.
• Reflux is considered primary when it is due to an incompetent UVJ and secondary when it is
due to increased bladder pressure or outlet obstruction.

• Presenting symptoms in neonates and infants include febrile illness or sepsis and may not be
localized to the urinary tract.

• The method of urine sampling, especially before toilet training, is crucial and may involve
suprapubic aspiration or per urethral catheter collection.

• A bacterial count of 50 000 colony-forming units per milliliter is generally considered a positive
culture result in children, although a lower count from a suprapubic aspirate in a symptomatic
child is significant.
• The most important complication of UTI in a child is renal scarring secondary to renal
parenchymal inflammation.

• US should be performed in all children, and children with recurrent UTIs or a first time UTI with
pyelonephritis should be evaluated further.

• VCUG is the investigation of choice to diagnose reflux and should be performed in high-risk
children. 99mTc dimercaptosuccinic acid (DMSA) radionuclide cortical scan is the best modality
to detect parenchymal lesions.
• VUR is present in approximately 30% of children with UTI and in up to 90% of children with
renal scarring.

• Renal scarring may cause hypertension in up to 20% and is an important cause of renal
failure.

• The grades of VUR are summarized in Figure 82.9, with grades I–III generally resolving
spontaneously.

• Low-dose nocturnal antibiotic prophylaxis to prevent scar-inducing pyelonephritis is the

mainstay of treatment as the majority of reflux cases resolve with time.

• However, surgery (ureteric reimplantation, periureteric injections of Tefon or collagen)

should be considered if episodes of acute pyelonephritis recur despite antibiotic therapy or
if severe reflux is accompanied by a surgically correctable malformation such as a
paraureteric bladder diverticulum.
Renal neoplasm
Benign tumors Malignant tumors
• Adenoma Wilms tumor
• Angioma • Age below five
• Angiomyolipoma • Lower pole
• omcocytoma • Unilateral
• The child present with renal mass
• Hypertension,
• Haematurea
• loin pain
Hypernephroma
• Adenocarcinoma
• 75%
• Usually unilateral, manly upper pole
• More in men
• Presentation, haematurea, mass pain, rapid forming Varicocele.
• Asymptomatic
• Metastesis
• Fever, polycythemia investigation
• CBP,LFT
• Renal function test
• Ultrasound
• IVU,CT scan

Treatment
• Radical nephrectomy
• Immunotherapy
• Tyrosin kinase inhibitors
 Tumours of the kidneys and ureters
Upper tract urothelial cancer
• Primary urothelial neoplasms of the renal pelvis and ureter are rare.

• They account for less than 10% of all urothelial tumors.

• They are more common in adult men.

• risk factors are tobacco consumption, occupations in the dye, petrochemicals and rubber
industries, analgesic abuse, high arsenic content in drinking water, exposure to
cyclophosphamide and the presence of chronic inflammation.

• Chronic inflammatory conditions are also associated with squamous cell carcinoma.
Presentation
• Patients commonly present with gross hematuria, with or without flank pain and occasionally
clot colic.

• Passage of long, slender, worm-like clots is suggestive of upper tract involvement.

• Patients with known bladder tumors should always be screened for upper tract tumors.

• Very few present with advanced constitutional symptoms and a palpable mass.

• Microscopic hematuria should be evaluated to exclude urothelial malignancy in the high-risk

adult (chronic smokers, occupational exposure, older age) population.
Pathology Diagnosis
• Both the PCS and the ureter have a thinner • Urinalysis may reveal numerous RBCs and
muscular layer than the bladder. white blood cells.

• Therefore, aggressive tumors of the upper • Urine cytology should be obtained.

tract can easily invade the muscle layers;
hence, the prognosis is poor. • The presence of atypical or malignant cells in a
freshly voided sample has a high specificity for
• Urothelial tumors can invade surrounding urothelial malignancies.
tissues, metastasize to regional lymph nodes
and spread haematogenously to lungs, liver • CTU, cystoscopy, retrograde pyelogram and
and bones. flexible ureterorenoscopy are required for
diagnosis.

• CTU is the investigation of choice

Benign renal tumors
• Incidental detection of renal lesions has increased owing to the widespread use of
abdominal imaging.
• The lesions may be cystic or solid.
• Solid renal tumors should be considered malignant unless proven otherwise.

Renal oncocytoma
• This derives its name from its cellular appearance on histopathology, where uniformly
highly granular eosinophilic cytoplasm owing to abundant mitochondria (oncocyte) is seen.
• It accounts for around 5% of renal tumors.
• It appears as an enhancing mass on cross-sectional imaging and is difficult to differentiate
from RCC.
Renal angiomyolipoma
• Angiomyolipoma comprises a composite mix of fat tissue with dysmorphic blood vessels
and smooth muscle.

• It is most often detected incidentally and has a female preponderance.

• Angiomyolipoma may be associated with syndromes such as the tuberous sclerosis

complex or it may be sporadic in nature.
Renal cell carcinoma
• RCC is the most common solid neoplasm of the kidney.
• It accounts for around 90% of renal tumors and constitutes 2–5% of all cancers in
adult men and 1–3% in adult women.
• There has been a recent steady increase in the incidence of RCC.
• It may be sporadic or familial.
Familial renal cell carcinoma
• von Hippel–Lindau syndrome is the most common familial syndrome associated with RCC.

• VHL disease is a rare autosomal dominant disorder that is characterized by multiple

pathologies, including
1. clear-cell RCC ,
2. phaeochromocytoma,
3. retinal angiomas,
4. haemangioblastomas of the brainstem, cerebellum or spinal cord.
Aetiology
• Cigarette smoking,
• obesity and hypertension are the major risk factors associated with RCC.

Others include
• diuretics,
• occupational exposure to petrochemicals and dyes and
• ARCD in patients on long-term hemodialysis.
Clinical presentation
• The classic triad of flank pain, hematuria and a palpable mass is now uncommon as most
renal masses are detected incidentally. Symptoms and signs may be non-specific.

• The most common presenting symptom is hematuria.

• Patients may have constitutional symptoms such as fever, malaise and weight loss in
advanced disease. Advanced disease can present with bilateral lower limb oedema or recent-
onset non-reducing right-sided varicocele owing to thrombus in the IVC.

• Paraneoplastic syndromes (PNSs) are found in up to one third of patients with RCC.

• The most common PNS is an elevated erythrocyte sedimentation rate (ESR) followed by
hypertension, anemia and hypercalcemia.

• Up to a quarter of the patients may have evidence of metastatic disease on presentation.

• The most common site of metastasis is the lung and is classically described as cannon ball
metastases. Metastases may occasionally present as pathological fractures.
Pathology
• ccRCC is histologically an adenocarcinoma arising from the proximal renal tubular epithelium.

• They are slow growing and bulge out of the renal contour.

• The tumor can spread directly, invading the perinephric tissue through the capsule or at times
directly extending into the renal vein as a tumor thrombus.

• Vein wall invasion is associated with poor prognosis

Diagnosis
• Blood count,
• ESR,
• Serum creatinine,
• Liver function tests,
• Lactate dehydrogenase (LDH),
• Corrected serum calcium,
• Coagulation markers,
• Urine analysis.

o Increased alkaline phosphatase should prompt further investigation to rule out liver and
skeletal metastases.
o LDH is useful in risk stratification of metastatic disease.

Investigations : Ultrasound , CT scan & MRI

Treatment : Radical or nephron-sparing nephrectomy, immunotherapy, Tyrosine kinase

inhibitors inhibit vascular endothelial growth factor
‫من المصدر ‪:‬‬
Wilms’ tumour
• This is the most common tumor of childhood, accounting for 5% of all childhood cancers.

• They are bilateral in 5% of cases and familial in 1%.

• The tumor has mixed elements derived from the embryonic nephrogenic tissue, namely
blastemal or undifferentiated tissue, epithelial tubules and stroma.

• The typical presentation is a child aged between 1 and 4 years of either gender with a
large,15 palpable abdominal mass that may cross the midline.

• It may also be associated with hematuria, hypertension, fever and weight loss.

• Pain is relatively uncommon.

• The large tumor can rupture and present as an acute abdomen.

• Other causes of renal masses include neuroblastoma, congenital mesoblastic nephroma, RCC,
clear-cell sarcoma and rhabdoid tumor.

• US can confirm the renal origin and solid nature of the mass.

• Further definitive imaging with either CECT or MRI is necessary to stage the disease.

• Up to 13% of patients have bilateral tumors.

• The tumors usually infiltrate the kidneys and normal renal parenchyma is compressed at the
periphery around the tumor (claw sign).

• A CT of the chest should be obtained as the lung is the most common site of distant metastasis.

• Current treatment is nephrectomy with pre- or postoperative chemotherapy.

• Both regimes have a comparable survival of ~90%.

‫للتوضيح ‪:‬‬