SURGERY OF THE KIDNEYS AND THE URETERS
By:
الدكتور
حارث محمد قنبر السعداوي
اختصاص جراحة الكلى واملسالك البولية والتناسلية والعقم
كلية طب الكندي
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جامعة بغداد
Embryology:
• Mesonephric origin: it forms the ureter, renal pelvis, calyces from 6
weeks to 8 months of intrauterine life.
• Metanephric origin: it forms the renal parenchyma.
The kidney ascends from 5th and 8th week of embryonic life to reach
the loin, and the hilum rotates medially 90 degree to face the vertebral
column.
Surgical anatomy:
• The parenchyma of each kidney drains to seven minor calyces which
will drains into three major calyces.
• Each of the three segments represents an anatomical and
physiologically distinct unit with its own blood supply.
Congenital abnormalities of the kidneys and ureters
• Renal aplasia:
• Renal ectopia: Horseshoe kidney, pelvic kidney
• Cystic diseases: Solitary cyst, infantile polycystic , autosomal
dominant polycystic kidney disease, unilateral multicystic diseases
• Aberrant renal vessels: multiple renal arteries & veins.
• Duplication: duplex kidney, duplex renal pelvis, duplex kidney and
ureter.
• Others: Retrocaval ureter, congenital megaureter.
.
Renal aplasia
usually discovered accidentally during I.V.U, or U/S. due
to failure of budding of the mesonephric bud, so there will
be absence of the ureter, ureteric orifice, renal pelvis and
the kidney . The contralateral kidney will be hypertrophied.
.
Horseshoe kidney
• Due to the fusion of the mesonephric buds in the midline, so the
lower poles of the two kidneys fuses , and the ascent of’ the
kidneys stopped at the origin of the inferior mesenteric vessels at
the level of the 4th lumber vertebra, more common in male.
clinical features:
1. Frequent infection & stone formation due to ureteric
angulation as they pass the fused isthmus
2. Associated pelvic-ureteric junction obstruction.
3. On examination a fixed mass below the umbilicus is
uncommon.
4. On I.V.U the lower pole calyces on both sides are directed
towards the midline, vas like curve of the ureters.
Unilateral fusion
• Rare, both kidneys are in one loin, and fused.
• the ureter of the lower kidney crosses the midline to the
contralateral side to open in the bladder)unilateral S
shaped kidney).
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Polycystic Kidney Disease
• Polycystic kidney disease (PKD) is a genetic disorder
characterized by the growth of numerous cysts. When
cysts form in the kidneys, they are filled with fluid. PKD
cysts can profoundly enlarge the kidneys while replacing
much of the normal structure, resulting in reduced kidney
function and leading to kidney failure.
• When PKD causes kidneys to fail—which usually happens
after many years—the patient requires dialysis or kidney
transplantation. About one- half of people with the most
common type of PKD progress to kidney failure, also called
end-stage renal disease (ESRD).
Two major inherited forms of PKD exist:
Autosomal dominant PKD is the most common inherited
form. Symptoms usually develop between the ages of 30
and 40, but they can begin earlier, even in childhood. About
90 percent of all PKD cases are
Autosornal recessive PKD is a rare inherited form.
Symptoms of autosomal recessive PKD begin in the earliest
months of life.
Autosomal dominant PKD
• Autosomal dominant PKD. autosomal dominant means that
if one parent has the disease, there is a 50 percent chance
that the disease gene will pass to a child.
• Many people with autosomal dominant PKD live for several
decades without developing symptoms. For this reason,
autosomal dominant PKD is often called “adult polycystic
kidney disease.”
Clinical features:
•Upper quadrant abdominal mass (renal enlargement).
• pain in the back and the sides
• Urinary tract infections—due to urinary stasis.
• hematuria:- due to rupture of the cyst into the renal pelvis
• high blood pressure
kidney stones
liver and pancreatic cysts
• Uremia: due to continuous replacement of the functioning
renal tissue with cysts.
Radiological examination:
• U/S, C.T. scan & MRI will show multiple cysts, if any doubt about
the content of the cyst (debris, blood) that gives suspicion of
malignancy, then cytological examination of the cyst fluid taken by
fine needle aspirate.
• l.V.U (spider’s legs or bell- like) appearance due to stretching of the
calyces over the cysts.
Treatment:
• Treatment of the renal failure – if developed — with low protien
diet, correct the anemia, treatment of infection.
• Surgical treatment by marcipulisation of the cyst (Rovsings surgery
rarely done today.
Other renal cystic diseases
• Solitary (simple) renal cyst: more than one cyst is often present in one or
both kidneys, usually discovered accidentally during radiological imaging of
the upper abdomen, or it may causes a palpable mass, pain due to
hemorrhage into the cyst, infection.
• Unilateral multicystic disease: Unilateral non — functioning renal mass in
the flank,
exploration & removal is required only when infection is a
problem, malignancy is suspected, or when mass effect is considerable.
• Infantile polycystic disease: autosomal recessive inheritance, rare,
incompatible with life.
Aberrant renal vessels
•
The renal arteries are functional end arteries, so division of any
aberrant artery will lead to infarction of the section of the
parenchyma that it supplies. Aberrant renal vein can be divided
since there are multiple venous collaterals.
•
Aberrant renal vessels may cause hydronephrosis due to pelvi-
ureteric junction obstruction.
Congenital abnormalities of the renal pelvis and ureter
Duplication of the renal pelvis:
it is found in 4% of the population, usually unilateral & is more
common on the left side.
Duplication of the ureter
• it is found in 3% of the population.
• usually the ureters join in the lower third & have common ureteric orifice.
• less commonly the, ureters open independently into the bladder, in which
case the ureter from the upper pelvis opens distal & medial to its fellow.
Clinical features:
• Infection, calculus formation, & PUJ obstruction are more common than in
normal kidneys.
• One of the moieties may be dysplastic and non-functioning.
• Vesicoureteric reflux is more common in the upper ureter draining the
lower moiety.
• An ectopic second ureteric opening may open distal to the external urethral
sphincter causing incontinence.
Treatment:
• Asymptomatic -- no treatment
• Partial nephrectomy for severely diseased renal moiety
• Reimplantation of the ectopic ureter to the bladder in case of incontinence
Ureterocele
• It is a cystic enlargement of the intramural portion of the
ureter due to congenital atresia of the ureteric orifice.
• The adder head’ on excretory urography is typical.
• Is more common in women.
• Usually associated with infection &/or stone formation.
• Treated by endoscopic diathermy incision.
Postcaval Ureter
• The right ureter passes behind the inferior vena cava instead
of lying to the right of it.
• if there are obstructive symptoms, the ureter can be divided
& rejoined in front of cava.
Congenital Megaureter
• hugely dilated ureter.
• Can be Obstructive, Refluxive or non-obstructive non-
reflexive megaureter
Renal Trauma
• trauma is generally caused by falls, road traffic accidents,
blows, sporting accidents, stab wounds and gunshot
wounds.
• Renal trauma can he classified as either blunt (non
penetrating) or penetrating..
Classification of Renal Injuries:
• GRADE I: contusion or contained sub-capsular hematoma,
without parenchymal laceration.
• GRADE II: non expanding confined peri-renal hematoma or
cortical laceration less than 1 cm deep, without urinary
extravasations.
• GRADE III: parenchymal laceration extending less than I cm into
the cortex without urinary extravasations.
• GRADE IV: parenchymal laceration extending through the
corticomedullary junction and into the collecting system. There
can be also thrombosis of a segmental renal artery without a
parenchymal laceration.
• GRADE V: three situations are possible:
- Thrombosis of the main renal artery;
- Multiple major lacerations;
- Avulsion of the main renal artery and/or vein.
Clinical Presentation:
• The cardinal sign of a renal trauma is haematuria, that can be massive
or microscopic, but the extent of the injury cannot be measured by the
volume of haematuria or the appearance of wound.
• Lumbar and the abdominal pain, sometimes with rigidity of the
anterior abdominal wall and local tenderness.
• Nausea and vomiting can be present. Extensive blood loss and shock
may result from retroperitoneal bleeding.
Investigation:
• Excretory urograrn.
• Ultrasonography
• CT scanning The CT scanning can distinguish better a major from minor
injury, can identify extravasations that were not demonstrated in
excretory urogram. It can also distinguish renal laceration and outline
an intrarenal haematoma.
• Arteriography it may reveal the actual bleeding vessel, show occlusion
of the main renal artery or its branches, and also renal lacerations.
Treatment:
• Most blunt renal injuries, including all grade I and 2 and most grade 3 and
4 injuries, can be safely treated without surgery. Patients require strict bed
rest until gross hematuria has resolved.
• Surgical repair is required for those with persistent bleeding, expanding
perinephric haematoma, or a renal pedicle avulsion.
• Penetrating trauma usually requires surgical exploration. although
observation may be appropriate for patients in whom the renal injury
has been accurately staged by CT, BP is stable. and no associated intra-
abdominal injuries require surgery.
Possible Complications:
• Secondary hemorrhage, usually due to infection ( I0 to I4 days after
trauma)
• Paralytic ileus (4 to 5 days) as a result of retroperitoneal hematoma
• Hypertension as a result of the constricting effect of reorganizing perirenal
haematoma.
• Arterio –venous fistula
• renal failure
• renal atrophy
• Hydronephrosis
• Chronic pyelonephritis
• renal calculi
• renal artery stenosis.
Injuries to the ureter
Rupture of the ureter:
- This is an uncommon result of a hyperextension injury of the spine. there
will be loin or iliac fossa swelling
- An excretion urograrn shows extravasations of contrast from the ureter
on the injured side.
Injuries to one or both ureters during pelvic surgery:
• this is far more common & occurs most often during vaginal or
abdominal hysterectomy.
• If the injury recognized at the time of operation: one of the following
should be done:
End to end anastomosis if there is no loss of length
Boari bladder flap operation if there is little loss of length.
Transureteroureterostomy, interposition of isolated bowel loop or
nephrectomy if there is marked loss of length.
• if the injury not recognized at the time of operation:
Unilateral injury:- clinically there are three possibilities:
1. No symptoms, with silent atrophy of the kidney
2. loin pain & fever (pyonephrosis) - temporary nephrostomy
should be done.
3. Urinary fistula through the abdominal wall or the vagina I.V.U
show extravasations of the contrast with or without
obstruction to one or both ureters - temporary nephrostomy
done followed later after months by surgical repair.
Bilateral injury : - the patient presented with anuria , urgent relief of
the obstruction is mandatory.
Hydronephrosis
It is an aseptic dilatation of the kidney due to partial or complete
obstruction to urine outflow.
Unilateral hydronephrosis : (due to ureteric obstruction).
causes include:
Extramural obstruction: tumour from adjacent structure ( colon , cervix ,
prostate, rectum) , idiopathic retroperitoneal fibrosis, reterocaval ureter.
Intramural obstruction: congenital stenosis, PUJ obstruction, ureterocele,
stricture, ureteric tumours or bladder tumours obstructing the ureteric
orifice.
Intraluminal obstruction: ureteric or renal pelvic stone, sloughed papilla due
to papillary necrosis.
Unilateral hydronephrosis( Clinical features)
Insidious onset of mild pain or dull aching in the loin, made worse by high
fluid intake.
Attacks of acute renal colic with no palpable swelling.
Bilateral hydronephrosis:
usually due to urethral obstruction (or the causes mentioned above
occurring on both sides).
The causes includes:
• Congenital: congenital stricture of the external urethral meatus, phirnosis,
posterior urethral valve, bladder neck contracture.
• Acquired: BPH, CA of the prostate, urethral stricture.
Bilateral hydronephrosis( Clinical features):
From lower urinary obstruction: symptoms of bladder outlet obstruction.
From bilateral upper urinary tract obstruction: similar to those of unilateral
obstruction (but on both sides).
From pregnancy: dilatation of the ureter and the renal pelvis occurs early in
the pregnancy, and becomes more marked until the 20th week. The
condition results from the effects of high levels of circulating, progesterone
on the ureteric smooth muscle, mechanical obstruction), the ureters return
to their normal size within 2 weeks after delivery.
lmaging:
- U/S
- Excretory urography: dilated pelvis, clubbed calyces (normally are
cupped), poorly functioning kidneys.
- Isotope renography.
Treatment : removal of obstruction and the aim is to conserve the renal
parenchyma.