Kidney surgical conditions😍

Weigert-Meyer Rule:

• Upper pole ureter:
• Ectopic insertion.
• Inferomedial to normal.

• Middle/lower pole ureter:
• Normal insertion.

Ectopic Sites:

• Male: Urethra.

• Female: Vagina (causes urinary dribbling).

Investigation:

Management:

• Ureter reimplantation.

• Known as joining hands or handshake or flower vase appearance
• Has association with Turner's syndrome.
• IVU: "Flower Vase" or "Hand Shake" sign.
• Fuse at isthmus
• Inferior mesenteric Artery → Anterior to isthmus → Prevent ascent

• Extrarenal Manifestations:
• Most common: Liver cysts.
• Cysts in spleen, pancreas, lungs.
• Colonic diverticulosis.
• Mitral valve prolapse.
• Berry aneurysms in Circle of Willis (can cause subarachnoid hemorrhage).

Xray

ADPKD

• On CT scan (Image 1), white bone is observed.
• Both kidneys are enlarged in size and have multiple cysts.

• On MRI (Image 2), black bone is observed.
• Both enlarged kidneys have multiple cysts.

• In IVP, initial or nephrogram phase:
• Multiple cysts do not take up the contrast,
• forming filling defects in the kidney.

• Spider leg appearance.
• d/t Splayed collecting system

• Swiss cheese appearance
• On nephrogram

ARPKD

• Striated appearance or sunray appearance of the kidneys.

• The kidney appears echogenic on ultrasonography.

Bosniak Classification for Renal Cysts

• Bosniak classification is used to group renal cysts based on malignancy risk.

• Anandhu → Bose now → has Renal cyst

Hydronephrosis

• Left kidney
• gray color density → fluid.
• Enhancing rim → renal parenchyma.
• Rim sign seen in hydronephrosis.

Ureterocele:

• IVU: "Cobra Head" or "Adder Head" sign.

• Cystic dilatation of ureteric terminal end.

• Surgery: Ureter reimplantation.

Retroperitoneal fibrosis (Ormond's disease)

• Can compress ureters → hydronephrosis

• "Maiden Waist" deformity, medial indrawing of ureters.

• Causes:
• Idiopathic
• post-radiotherapy
• drug-induced (Methysergide).

• Management: DJ Stenting.

• Mnemonic: Purakil ninn (retroperioneal) DJ () kalikkunna Maid () ne Ormayundo (Ormond)

Retrocaval ureter:

• Right ureter passes behind IVC.

• Hydronephrosis + hydroureter (of the proximal ureter)

• "Reversed J" or "FishHook" sign.

• Technetium-99m

• DMSA:
• Mnemonic: Morphology → Scar → Static
• Used for kidney scars or morphological changes.
• Detects if the kidney is located ectopically.
• It is a static scan.
• no GFR or tubular function

• DTPA:
• Gives the function/physiology of the kidney (GFR).

• MAG3:
• Mnemonic: Magnificient
• Helps in evaluating GFR and tubular function.

Whitaker Test – Used to differentiate between obstructive vs non-obstructive hydronephrosis

Principle:

• Measures differential pressure between the renal pelvis and bladder during fluid infusion.

Procedure:

• A percutaneous nephrostomy is created (puncture through loin into the renal pelvis).

• Normal saline or contrast is infused at a constant rate (typically 10 mL/min) into the renal pelvis.

• Simultaneous measurement of pressure in:
• Renal pelvis
• Bladder

Interpretation:

• Normal: Renal pelvic pressure stays <22 cm H₂O.

• Obstruction:
• Renal pelvic pressure >22–25 cm H₂O, or a
• pressure gradient >15 cm H₂O between renal pelvis and bladder.

• While taking water (Whitaker)

Uroflowmetry

• >15 ml/sec: Normal.

• 10-15 ml/sec: Equivocal.

• <10 ml/sec: Low flow.

Christmas or pine or fir tree appearance

• Seen in neurogenic bladder.

• The tone of the bladder is affected, causing a shape change from round to elongated.

• Multiple diverticuli are present.

Teardrop or pear shape or inverted pear shape appearance

• In an IVP image, the bladder appears to have a teardrop shape.

• A normal bladder is compressed by external forces, causing elongation.

• Causes include:
• Extrinsic compression of the bladder.
• Any pelvic cause.
• e.g., pelvic lipomatosis, pelvic abscess, pelvic hematoma, pelvic lymphadenopathy, pelvic vessel aneurysm.

Fetal skull calcification of the urinary bladder

• Seen in schistosomiasis.

• Bladder wall calcification

• Schistosoma haematobium resides in the vesical venous plexus of the bladder.

• Calcium Ammonium Magnesium Phosphate.

• Associated with
• Proteus urinary tract infection.
• Parathyroid adenoma → Hypercalcemia → Calcium deposits in kidney

• Radio-opaque.

• "Coffin Lid" shaped.

• Formed in alkaline urine.

• Features
• Smooth surface, large size.
• takes up the shape of the pelvis and calyces.
• Calcification with lobulated appearance, i.e. parenchymal

• Coffin lu avathirikkan Maaninte (Staghorn) irachi thinnanam + Protein (Proteus) thinnanam→ Strong (Struvite) avanam

• DMSA scan for scarring.

• CT Urography (also Radiolucent) >> Non-contrast CT (NCCT)

• Partial vs complete obstruction: Diuretic DTPA scan

Ureteric calculi

• Ureteric stone is generally vertically oval.

Renal Calculus

• A white area (right kidney) → right renal calculus
• Right kidney + psoas major muscle located posteromedially.

• On ultrasound → echogenic area + shadow behind it.
• Shadow → posterior acoustic shadowing.

B/L Nephrocalcinosis/ Medullary Nephrocalcinosis

• Lucent areas are observed between opaque areas.

• 2 causes
• A/w Hyperparathyroidism
• Medullary sponge kidney

• Functional kidney

• Dense calcification in the center of the pelvis is observed.

• This is the bladder stone or vesical calculus.

• DMSA scan for scarring.

Imaging in PUV

• Management: Fulguration of the valve.

Renal artery stenosis

• Affects the ostium.

• Young patient (without a family history of hypertension)

• 1st investigation is renal Doppler (Image 1)
• has a slow and blunted uptake.
• i.e. pulsus parvus et tardus waveform (Image 2)
• Normal renal artery has a quick upstroke.

• 2nd investigation is CT-angiography or MR-angiography.

• Gold standard procedure is digital subtraction angiography (DSA).

Fibromuscular dysplasia

• Beaded appearance.

• Seen in an MR-angiography.

• Indicates multiple strictures in the renal artery.

• Common in young adult females.

• Also presents with hypertension (similar to renal artery stenosis).



 

Urethra

Length

• Female: 3-4 cm.

• Male: 18-21 cm.

Parts

• Proximal: Membranous + Prostatic Urethra.

• Distal: Penile + Bulbar Urethra.

Epithelium of Male Urethra

Transitional epithelium / urothelium lines

• Renal pelvis and calyces,

• ureter

• urinary bladder

• pre-prostatic & prostatic parts of the urethra

Renal Tuberculosis

Features:

• Secondary infection (hematogenous spread).

Presentations:

Renal

• Papillary Ulcers → Ghost calyx/Pseudo calculi → Caseous necrosis → Pus filled kidney → Calcification ("Putty" or "Cement" kidney).

Ureter

• Kirrs Kink
• Bending of ureter

• Shortening of ureter

• Golf hole ureteric orifice
• Orifice remain open

• Pale ureteric orifice
• Indicates inflammation and edema of surrounding mucosa
• Early sign

Clinical Features:

• Hematuria, pain, mass, weight loss.

Putty kidney

• Cement (amorphous calcification) + lobulated appearance = parenchymal calcification

• Moth eaten calyces
• Earliest sign in the IVP for renal TB
• irregularity of the calyx.

• Later stages of TB

• → non-functional kidney and auto-nephrectomy.

• Sterile pyuria is seen in urinary TB.

Corkscrew and Beaded appearance

• Multiple ureteric strictures

Thimble bladder

• small, contracted bladder

• Heal with fibrosis
• bladder wall calcification

Investigations:

• Urine examination: Sterile pyuria (pus cells +, culture -).

• Confirmatory:
• ZN Staining of centrifuged 3 morning urine samples.

Note:

• If genital TB
• Genital swab for polymerase chain reaction (PCR) testing

Treatment:

• Medical: Anti-tubercular treatment (ATT).

• Surgical (for complications):
• Perinephric abscess:
• Drainage.

• Ureteric kinking:
• DJ stenting.
• "Golf Hole" ureteric orifice:
• Ureteric reimplantation.
• "Thimble Bladder":
• Augmentation cystoplasty.
• Lower ureter damage:
• Boari flap repair.

• Black areas
• Air is contained within the kidney and surrounding it.

• Organism: E.coli.
• Note: clostridium → emphysematous cholecystitis

• Common in immunocompromised, DM patients.

• Can turn fulminant and septic.

• IOC: CECT (gas in/around kidney).

• Management: Antibiotics + drainage.

Acute pyelonephritis

• In acute pyelonephritis, the kidney is enlarged.

• In chronic pyelonephritis, the kidney is shrunken.

• Enlarged edematous kidney → Total / Focal

• A striated appearance is observed.

• Reduced areas of cortical vascularity on power Doppler

Renal Papillary Necrosis

• Signet ring appearance.

• Contrast is seen around the necrosed papilla.