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Author(s): J. Stuart Wolf, Jr., M.D., 2009

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Kidney and
   Upper Urinary Tract

            J. Stuart Wolf, Jr., M.D.
              Professor of Urology



Fall 2008
Michigan Urology Center
 University of Michigan
    Ann Arbor, MI
Kidney and Upper Urinary Tract

Syllabus
  !    If I show you graphics that are NOT in
       your syllabus
        !    Then they are NOT critical for the
             test
        !    They are to familiarize you with
             Urologic operative techniques, for
             their interest rather than for testing
             purposes
  !    Radiography will be on test, but not the
       actual images
Kidney and Upper Urinary Tract

Objectives
  !    Appreciate importance, evaluation, and
       differential diagnosis of hematuria
  !    Gain basic understanding of major
       disease processes of kidney and upper
       tract
        !    Obstruction
        !    Calculi
        !    Infection
        !    Renal masses and cysts
Kidney and Upper Urinary Tract

Clinically-Oriented Lecture

            Hematuria

   Evaluation and Differential

     Case presentations of
     representative entities
Hematuria

Hematuria
  !    Definition
        !    > 3 RBC / hpf in urinary sediment
        !    Dipstick is screening test only
        !    Dipstick is 95 % sensitive, but only
             about ~ 80% specific
        !    In population with 10% hematuria, PPV
             of Dipstick is only 35%
        !    Positive Dipstick indicates hematuria
             ONLY when confirmed by microscopy
             of > 3 RBC / hpf
Hematuria

Hematuria
  !    Additional Characterization
        !    Gross (grossly visible) or microscopic?
              –  Gross   more likely significant
        !    If gross, is it initial (urethra), terminal
             (bladder neck or prostate), or total
             (interior of bladder or upper tract)
Hematuria

Evaluation 1: Examine Urine
  !    In women, get cath. UA if > 1 squamous
       cell / hpf (vaginal contamination)
  !    Is color red but dipstick - ?
        " Consider phenolphthalein, rhodamine B,
          others
  !    Is dipstick + but no RBC present?
        " Beware if specific gravity < 1.008 (RBC
          may have been there, but lysed)
        " Usually false positive test

        " Unfortunately,   a common referral
Hematuria

Evaluation 1: Examine Urine
  !    Is there pyuria or bacteruria?
        " Probable   infection (any GU site)
  !    Is there proteinuria (> 2 + on dipstick), or
       are there dysmorphic RBCs or RBC casts?
        " Probable   glomerulonephritis
Hematuria

Evaluation 2: History and Physical
  !    Flank Pain
        "  Stone

  !    Dysuria, bladder irritability
        "  Bladder     or prostate infection
  !    Sickle cell, diabetes
        "  Papillary   necrosis
  !    Family or personal history of calculi,
       PCKD, other GU / Neph diseases
        "  Possible    familial trait
Hematuria

Evaluation 2: History and Physical
  !    Trauma, or intense physical activity
        "  May    be cause of hematuria
  !    Tobacco use, occupational chemical
       exposure (aromatic dyes)
        "  Risk   for renal and urothelial cancers
Hematuria

Evaluation 2: History and Physical
  !    Visible blood at urethral meatus
        "  Urethral    source
  !    Fever, CVAT
        "  Pyelonephritis

  !    Prostate exam
        "  Prostatitis,   Prostate cancer
  !    Pelvic Exam
        "  Urethral,   vaginal, or labial lesions
Hematuria
Evaluation 3: Labs and Procedures
  !    Formal urinalysis with microscopic
       examination
  !    Urine culture
        !    If infection is DOCUMENTED, then
             can omit rest of work-up if hematuria
             clears with antibiotics
  !    IVU versus KUB + US versus CT
  !    +/- Urine cytology
  !    +/- Serum electrolytes and creatinine
  !    Cystoscopy
Hematuria

Diagnostic Categories
  !    Infection
  !    Calculi
  !    Cancer
  !    Benign neoplasms / lesions
  !    Other obstruction
  !    Trauma / exertional hematuria
  !    Medical renal disease
  !    Blood dyscrasia / anticoagulation
  !    Benign familial hematuria
Hematuria

Infection
  !    Kidney
        !  Pyelonephritis - parenchyma

        !  Pyonephrosis - pus in collecting system

        !  Renal abscess - pus pocket in

           parenchyma
Hematuria

Infection
  !    Bladder
        !  Bacterial cystitis

  !    Prostate
        !  Bacterial prostatitis

  !    Urethra
        !  Infectious urethritis
Hematuria

Calculi
  !    Kidney
        !  Obstructive vs. Non-obstructive

        !  Simple vs. Staghorn

  !    Ureter
        !  Obstructive vs. Non-obstructive

  !    Bladder
Hematuria
Cancer
  !    Kidney
        !  Renal cell carcinoma, other

  !    Upper collecting system
        !  Urothelial, other

  !    Bladder
        !  Urothelial, other

  !    Urethra
        !  Squamous cell, other

  !    Prostate
        !  Adenocarcinoma, other
Hematuria

Benign Neoplasms / Lesions
  !    Kidney
        !  Simple cysts

        !  Cystic renal diseases

        !  Angiomyolipoma, other neoplasms

  !    Ureter
        !  Hemangioma, other

  !    Bladder
        !  Endometrioma, other

  !    Urethra
        !  Condyloma, other
Hematuria

Other Obstructions
  !    Ureter
        !  Ureteropelvic junction (UPJ)

        !  Intrinsic strictures

        !  Extrinsic obstruction

  !    Bladder
        !  Bladder outlet obstruction (BOO)

             –  Benign prostatic hyperplasia (BPH)
             –  Other
  !    Urethra
             –  Strictures, other
Hematuria

Trauma / Exertional Hematuria
  !    Cannot be assumed to be cause
Medical Renal Disease
  !    Previous Nephrology lecture
Blood Dyscrasia / Anticoagulation
  !    Cannot be assumed to be cause
Benign Familial Hematuria
  !    Microscopic only, negative work-up
Kidney & Upper Urinary Tract

Kidney, Intra-renal Collecting
 System, and Ureter
  !    Topics covered (case presentations)
        !  Ureteral obstruction (UPJO)

        !  Calculi (ureteral, renal)

        !  Infection (pyelonephritis)

        !  Cancer (renal cell carcinoma)

        !  Renal cystic disease (ADPKD)
Kidney & Upper Urinary Tract: Obstruction

Case 1: Ureteropelvic Junction
 Obstruction (UPJO)
  !    24 year old woman
  !    Long history of intermittent left flank
       pain, recently worsening
  !    Not during sleep
  !    Especially notices after fluid intake, or
       even more after drinking alcohol
  !    No significant medical history
Kidney & Upper Urinary Tract: Obstruction

Case 1: Ureteropelvic Junction
 Obstruction (UPJO)
  !    Young age - diagnosed mostly in
       children, variable after that
  !    Intermittent symptoms - typical of adult
       presentation
  !    Pain increased with fluid intake
        !    Classic for UPJO
        !    Flow-dependent obstruction (like a
             slow but not-yet clogged drain)
Kidney & Upper Urinary Tract: Obstruction

Anatomy of Kidney and Upper
 Urinary Tract
  !    Paired Kidneys
  !    Urine from collecting tubules that
       terminate in papillae drain into:
        !    Calyces, that coalesce into
        !    Infundibula, which drain into
        !    Renal Pelvis
  !    Travels down ureter (peristalsis)
Kidney & Upper Urinary Tract: Obstruction

                Calyx          Renal Pelvis




Infundibulum
J.S. Wolf
Kidney & Upper Urinary Tract: Obstruction

Anatomy of Kidney and Upper
 Urinary Tract
  !    Tight spots     prone to obstruction
       !    Ureteropelvic junction (UPJ)
       !    Mid-ureter as crosses iliac vessels
            (over sacrum on plain radiograph)
       !    Ureterovesical junction (UVJ)
  !    Of these, the UPJ most common site of
       congenital obstruction
Gray s Anatomy
Gray s Anatomy
Image removed
Kidney & Upper Urinary Tract: Obstruction
Case 1: Ureteropelvic Junction
 Obstruction (UPJO) Evaluation
  !    Intravenous urogram
        !    Unilateral hydronephrosis and non-
             visualization of ureter
  !    Diuretic renal scintigraphy
        !    50% split renal function
        !    T 1/2 (time for ! of tracer to exit
             kidney) on symptomatic side > 100
             minutes (normal < 10 minutes)
Intravenous
Urogram                             Left
                                    hydronephrosis
                                    and non-
                                    visualization of
                                    the ureter




              Source Undetermined
Diuretic Renal Scintigraphy




   Source Undetermined


Excretion from left kidney is delayed
Kidney & Upper Urinary Tract: Obstruction

Case 1: Ureteropelvic Junction
 Obstruction (UPJO) Treatment
  !    Percutaneous endopyelotomy
        !    A minimally-invasive alternative to
             formal pyeloplasty
  !    Nephro-ureteral stent capped off in 1
       week, and removed in 6 weeks
        !    Complete resolution
Kidney & Upper Urinary Tract: Obstruction
Causes of UPJO
 !    Primary
       !  Histological disorganization

           –  excess longitudinal muscle fibers
              (loss of normal organization)
           –  increase in collagen
           –  attenuation of muscle bundles
       !  Crossing vessels, high insertion, kinks,

          bands
 !    Secondary
       !  Traumatic scar, iatrogenic scar, external

          compression (think cancer!)
Kidney & Upper Urinary Tract: Obstruction
Evaluation of UPJO
  !    Determine presence and degree of
        obstruction
        !    Is there obstruction, or just dilation?
        !    Complete or partial obstruction?
  !    Determine renal function
        !    If kidney not working well, may be
             little value in repairing
  !    Determine cause of obstruction
Kidney & Upper Urinary Tract: Obstruction
Dilation of the Urinary Tract
  !    Non-obstructive
        !  Ureteral reflux, prior obstruction, extra-
           renal pelvis, diuresis
        !  Stagnation may lead to infection and

           calculi, but usually innocuous
  !    Obstructive
        !  Increased resistance to urine flow that

           produces increased proximal pressure and
           subsequent loss of organ function
        !  Occasionally difficult to distinguish from

           non-obstructive
Massive Vesico-ureteral Reflux on Cystogram




               Source Undetermined
Kidney & Upper Urinary Tract: Obstruction
Evaluation of UPJO
  !    Anatomic tests
        !  Intravenous urography

        !  Renal (surface) ultrasonography

        !  Computed tomography

        !  Endoluminal ultrasonography

  !    Functional tests
        !  Ultrasonography with resistive indices

        !  Diuretic renal scintigraphy

        !  Whitaker test
Intravenous
Urography

  Normal
  kidney


                                    Hydronephrosis




              Source Undetermined
Renal Ultrasonography     Hydronephrosis




    Source Undetermined
Computed Tomography
Can determine additional anatomy, including
vessels crossing at UPJ




          Source Undetermined
Computed Tomography
Can determine additional anatomy, including
vessels crossing at UPJ




             Source Undetermined
Endoluminal Ultrasonography
Can detect vessels crossing over UPJ, but
requires retrograde catheterization




            Source Undetermined
Ultrasonography with Resistive Indices
(PSV - LDV) /PSV: Normal




    Diastolic flow velocity is preserved
    Source Undetermined
Ultrasonography with Resistive Indices
(PSV - LDV) /PSV: Obstructed




   Source Undetermined


 As resistance to blood flow increases,
 diastolic flow velocity decreases, and
 resistive index increases (R.I. > 0.70)
Diuretic Renal Scintigraphy: most
definitive non-invasive test
T ! = Time for ! of radiotracer to be
excreted from kidney after furosemide




 T ! = 5 minutes
                         T ! = 25 minutes
 (normal < 10 min.)
                         (obstructed > 15 min.)
  Sources Undetermined
Whitaker Test: most definitive test
Pressure in renal pelvis at set infusion rate
through nephrostomy tube (> 15 mmHg at
15 cc/min infusion = obstruction)




            Source Undetermined
Kidney & Upper Urinary Tract: Obstruction

Treatment of UPJO
                                          Most
 !    Open pyeloplasty               Invasive / Most
                                        Effective
 !    Laparoscopic pyeloplasty

 !    Percutaneous endopyelotomy

 !    Retrograde balloon dilation        Least
 !    Retrograde endopyelotomy      Invasive / Least
 !    Acucise® (cutting balloon) endopyelotomy
                                       Effective
Break
Kidney & Upper Urinary Tract: Calculi

Case 2: Acutely Obstructing Distal
 Ureteral Calculus
  !    30 year old man
  !    Sudden onset of right flank pain
  !    Initial gross hematuria, but now clear
  !    No fevers and chills, but nausea
  !    Frequent urination
  !    Pain somewhat less after a few hours
  !    Restless, moving about
  !    Right flank, lower quadrant, and testicular
       pain / tenderness
  !    5 - 10 RBC / hpf on urinalysis
Kidney & Upper Urinary Tract: Calculi
Case 2: Acutely Obstructing Distal
 Ureteral Calculus
  !    Sudden onset pain - c/w renal colic
  !    Urine cleared - suggests obstruction
  !    Nausea - very common with renal colic
  !    Freq. urination - irritation by distal calculi
  !    Pain decreased - forniceal rupture, decrease in
       pressure from renal hemodynamics
  !    Moving about - NOT peritonitis
  !    Flank to scrotum - expected radiation
  !    Urinalysis - RBCs in 85%
Kidney & Upper Urinary Tract: Calculi

Suspected Acute Ureteral Obstruction
 Differential Diagnosis
  !    Intrinsic
        !  Calculi, tumor, clot, edema

  !    Extrinsic
        !  Compression by tumor, lymph node

  !    Acute versus acute-on-chronic
        !  Calculi, or calculi impacted into partially-

           obstructing stricture?
        !  Clot, or clot on tumor?
Kidney & Upper Urinary Tract: Calculi

Suspected Acute Ureteral Obstruction
 Radiographic Evaluation
  !    KUB and Intravenous urography
        !  Anatomic picture, localize pathology

  !    Ultrasonography
  !    CT
        !  Non-contrast (stones)
        !  CT urogram (with contrast, like IVU)

  !    Retrograde pyelography
        !  Injection through catheter
Intravenous
                                    This stone
Urography                           is less
                                    dense than
                                    contrast
                                    material, so
                                    appears as
                                    filling
                                    defect




              Source Undetermined
Intravenous Urography


                        This stone
                        is faintly
                        radio-
                        opaque …




  Source Undetermined
Intravenous Urography
                        … and is
                        easier to
                        identify when
                        contrast
                        material
                        comes down
                        to it



  Source Undetermined
Kidney & Upper Urinary Tract: Calculi

Spontaneous Passage of Ureteral
 Stones
                   Width         ProximalMiddle        Distal
                             4 mm        20%   45% 55%
                             5 mm        6%    30% 45%
                             6 mm        0%    10% 25%
       100%

             50%

             0%
                   1     2   3   4   5    6    7   8    9   10

 J.S. Wolf
Ultrasonography




                      Hydronephrosis
Source Undetermined
(almost) all
Computed Tomography   stones dense
                      on CT




Source Undetermined
Computed Tomography




     Source Undetermined

Secondary signs of ureteral obstruction
Computed Tomography




      Source Undetermined



Secondary signs of ureteral obstruction
Computed
Urography




            Source Undetermined
Intravenous Urography


                      Irregular
                      Filling
                      Defect




Source Undetermined
Kidney & Upper Urinary Tract: Calculi

If        filling defect    on contrast study …
     !    Neoplasm
           !  Urothelial neoplasm most common

     !    Blood clot
           !  Will resolve during follow-up

     !     Radio-lucent calculus (15%)
           !  Other 85% are calcium containing

           !  Refers to appearance on plain film (all

              typical stones are opaque on CT scan)
           !  Radio-lucent stones are usually uric acid

              (only medically dissolvable stone)
     !    Need to rule-out tumor!
Kidney & Upper Urinary Tract: Calculi

Case 3: Non-obstructing Renal
 Calculus
  !    65 year old man
  !    Microscopic hematuria
  !    Remote history of urolithiasis
  !    Mild prostatism
  !    Unremarkable PE except for prostatic
       enlargement
  !    Urinalysis - 10 RBC / hpf
Plain
Radiography




 Densely
 radio-
 opaque
 stones


              Source Undetermined
Kidney & Upper Urinary Tract: Calculi

Indications for Surgical Treatment of
  Urolithiasis
  !    Urinary tract infection
  !    Significant obstruction
  !    Pain refractory to oral medication
  !    Others
        !  Staghorn calculi - risk of urosepsis

        !  Long-standing ureteral calculi - eventual

           obstruction
        !  Occupational or lifestyle reasons
Plain
Radiography




 Staghorn
 Calculus



              Source Undetermined
Kidney & Upper Urinary Tract: Calculi
Surgical Treatment of Urolithiasis
  !    Open surgical / laparoscopic      Most
       lithotomy                    Invasive / Most
                                       Effective
  !  Percutaneous nephrostolithotomy

     (Antegrade endoscopy)

  !    Ureteroscopy (Retrograde
       endoscopy)
                                            Least
  !    Extracorporeal shock wave       Invasive / Least
       lithotripsy (SWL)                  Effective
Source Undetermined
Source Undetermined
Image removed
Source Undetermined
Source Undetermined
Source Undetermined
Kidney & Upper Urinary Tract: Calculi

Parameters Determining Treatment of
 Urolithiasis
  !    Size
  !    Location
  !    Composition
  !    Medical Condition, Patient Preference,
       Physician Preference
Kidney & Upper Urinary Tract: Calculi

Size
  !    Small
       !    SWL
  !    Moderate
       !    Ureteroscopy
  !    Large
       !    Percutaneous nephrostolithotomy
Kidney & Upper Urinary Tract: Calculi

Location
  !    Distal Ureter
        !    Scope > SWL
  !    Middle Ureter
        !    Scope > SWL
  !    Proximal Ureter
        !    SWL > Scope ?
  !    Kidney
        !    SWL > Scope
Computed Tomography




     Source Undetermined



Distal aspect of UVJ, almost in bladder
Computed Tomography




Source Undetermined


          Huge bilateral renal calculi
Kidney & Upper Urinary Tract: Calculi

Composition
  !    Dense (Calcium oxalate monohydrate)
        !  Scope

  !    Fuzzy/ Faint (Calcium oxalate dihydrate,
       calcium phosphate, struvite)
        !  SWL

  !    Cystine
        !  Scope

  !    Uric Acid
        !  SWL
Plain
Radiography




 Densely
 radio-
 opaque
 stone


              Source Undetermined
Plain Radiography

   Fuzzy
  radio-
  opaque
  stone




 Source Undetermined
Kidney & Upper Urinary Tract: Pyelonephritis

Case 4: Pyelonephritis
  !    29 year old woman
  !    Started with 3 days of dysuria (painful
       urination), urinary frequency / urgency
  !    Now temp 101.7º C, right flank pain
  !    History
        !  Occ previous UTI

        !  Recently married

        !  Limited sexual activity before marriage,

           now active
  !    PE - Right CVAT
Kidney & Upper Urinary Tract: Pyelonephritis

Case 4: Pyelonephritis
  !    Young woman - UTI is common
  !    Initial cystitis (infection ascends) common
       and suggest UTI
  !    Systemic symptoms - distinguishes upper
       from lower tract UTI
  !    Previous UTI - helps establish her
       characteristic symptoms of UTI
  !    Sexual activity - predisposing factor for
       UTI in women
  !    CVAT - renal involvement
Kidney & Upper Urinary Tract: Pyelonephritis

Acute Pyelonephritis
  !    Most common disease of the kidney
  !    Usually ascending infection
  !    Diagnosis by clinical findings and urine
       culture (85% are GNR; E. Coli)
  !    Imaging used to detect complications or
       to assess for predisposing factors
  !    Complications: papillary necrosis,
       pyonephrosis, abscess, sepsis
  !    Predisposing factors: obstruction, calculi,
       vesico-ureteral reflux
Source Undetermined


            Lobar Nephronia
Kidney & Upper Urinary Tract: Pyelonephritis

Management of Acute Pyelonephritis
  !    Typical case - fever resolves within 48 hrs
       of starting antibiotics
        !  Oral abx in most

        !  Intravenous abx if very ill-appearing

  !    Debilitated patients at greater risk
        !  Diabetes mellitus

        !  Steroids

        !  Chronically ill

        !  Immuno-suppressed
Kidney & Upper Urinary Tract: Pyelonephritis

Management of Acute Pyelonephritis
  !    History of complications or lack of
       response to antibiotics
         "  US or CT for obstruction, calculi

  !    Upper tract obstruction with infection
         "  DRAINAGE (stent, percutaneous tube)

  !    Upper tract calculus with infection
         "  Treat acute infection, then calculus

  !    If child or recurrent
         "  US for scars

         "  Voiding cystogram for reflux
Kidney & Upper Urinary Tract: Pyelonephritis

Drainage procedures
  !    Percutaneous nephrostomy tube


                      Image of a
                    percutaneous
                    nephrostomy
                    tube removed




  !    Ureteral stent


           Hildpeyi, wikimedia commons
Break
Kidney & Upper Urinary Tract: Masses & Cysts

 Case 5: Renal Cell Carcinoma (RCC)
   !    64 year old man
   !    Gross hematuria
   !    Flank pain
   !    History
         !  66 pack-year smoker

   !    PE
         !  Fullness in right flank
Kidney & Upper Urinary Tract: Masses & Cysts

 Case 5: Renal Cell Carcinoma (RCC)
   !    Older man - peak in 6th decade, 3:1
        M:F overall
   !    Hematuria - most common presenting
        sign
   !    Flank pain and flank mass - along with
        hematuria, the classic triad
   !    Smoking - major acquired risk factor
Kidney & Upper Urinary Tract: Masses & Cysts

 Demographics of RCC
   !    Incidence: 12.8 per 100,000 ( 00 - 04)
   !    Mortality: 4.2 per 100,000 ( 00 - 04)
   !    estimated 51,190 new cases in 2007
        (~2% of adult malignancies)
   !    estimated 12,890 deaths in 2007
   !    Lifetime Risk (M / F)
         !    Risk of occurrence - 1.71 / 1.01 %
         !    Risk of death - 0.59 / 0.35 %
   SEER Cancer Statistics
Kidney & Upper Urinary Tract: Masses & Cysts

 Risk factors for RCC
   !    Cigarettes
   !    Obesity
   !    Hypertension
   !    Occupational exposures
   !    Dialysis
   !    Hereditary
         !    von Hippel-Lindau disease
         !    Tuberous Sclerosis
Kidney & Upper Urinary Tract: Masses & Cysts

 Pathology of RCC
   !    Proximal tubular cell neoplasm
   !    Often venous involvement
   !    Hemorrhagic, necrotic, cystic, and
        calcified components common
   !    Metastasize most commonly to lung,
        liver, bone, adrenal, and contralateral
        kidney
Kidney & Upper Urinary Tract: Masses & Cysts

Common Renal Tumors
  Pathology        Malignant?   Relative %

  Renal Cell Ca.      Yes          85%
  Urothelial Ca.      Yes          5%
  Oncocytoma          No           5%
  Other            Most not        5%
Kidney & Upper Urinary Tract: Masses & Cysts

 Histology
    !    Most Renal Cell Carcinomas have
          Clear cell histology
         !    Lipids (dissolve out during slide
              processing) and glycogen
         !    Fuhrman grading (1 to 4)
               –  1   = well differentiated
               –  4   = poorly differentiated
Kidney & Upper Urinary Tract: Masses & Cysts

 Genetics
    !    Most renal cell carcinomas are sporadic
    !    Are associated with several syndromes,
         the most common of which is Von-
         Hippel Lindau syndrome
          !  Autosomal dominant

          !  Cerebellar and retinal vascular tumors

          !  Adrenal and renal tumors (inc cysts)
Kidney & Upper Urinary Tract: Masses & Cysts

 Genetics
    !    Von-Hippel Lindau syndrome
          !  Autosomal dominant

          !  Mutation in VHL tumor suppressor

             gene: 3p25-26
    !    95% of sporadic clear cell renal cell
         carcinomas have VHL mutation
          !  One of the strongest associations

             among solid tumors
          !  Opportunities for gene therapy
Kidney & Upper Urinary Tract: Masses & Cysts

 Symptoms / Signs of RCC
   !    Hematuria (29 – 60%)
   !    Flank pain (14 – 51%)
   !    Flank mass (21 – 47%)
   !    All 3 = Classic triad
         !    Present in < 10%
         !    Usually signifies advanced disease
Kidney & Upper Urinary Tract: Masses & Cysts

  Paraneoplastic Syndromes
     !    ESR elevation
     !    Calcium elevation
     !    Polycythemia
     !    Anemia
     !    Thrombophlebitis
     !    Hyperinsulinism
     !    LFT elevation
Kidney & Upper Urinary Tract: Masses & Cysts

 Central Role of Imaging

    Simple Cyst             Benign


 Indeterminate
          Cyst               ?


     Solid Mass             Malignant
Kidney & Upper Urinary Tract: Masses & Cysts

 Stage Migration of RCC due to
   more frequent imaging
   !    1970 s
         !  4% of RCC < 3 cm

         !  32% presented with metastases

   !    1980 s
         !  25 - 40% were incidental finding

         !  25% of RCC < 3 cm

         !  17% presented with metastases

   !    1990 s
         !  60% were incidental finding
Kidney & Upper Urinary Tract: Masses & Cysts

 Imaging Modalities
    !    Intravenous Urography (IVU, IVP)
    !    Ultrasonography (US)
    !    Computed Tomography (CT)
    !    Magnetic Resonance Imaging (MRI)
Kidney & Upper Urinary Tract: Masses & Cysts

Intravenous Urography
  !    Typical upper tract imaging for hematuria
       work-up
  !    Excellent visualization of collecting system
  !    Renal mass or cyst causes displacement
       of surrounding organ or deformation of
       outline
  !    Screening study only
  !    If renal mass / cyst suspected, further
       imaging is required
Intravenous
Urography




  Mass Effect
  in kidney



                Source Undetermined
Kidney & Upper Urinary Tract: Masses & Cysts

 Ultrasonography
   !    Usual follow-up to IVU suspicious for
        renal mass / cyst
   !    No ionizing radiation
   !    Non-invasive
   !    Operator dependent
   !    Reliably identifies simple cyst (85% of
        renal mass / cysts)
   !    If NOT a simple cyst
         !  Cross-sectional   imaging
Ultrasonography




      Simple Cyst
Source Undetermined
Kidney & Upper Urinary Tract: Masses & Cysts

Sonographic Characteristics
  !    Anechoic with enhanced through
       transmission
        !  Simple cyst
  !    Echogenic with acoustic shadowing
        !  Stone or other calcification
  !    Iso / hypoechoic mass
        !  Solid mass
Ultrasonography




          Renal Stone
Source Undetermined
Ultrasonography




Nodule in Cyst
Source Undetermined
Ultrasonography




Source Undetermined
                      Solid Mass
Kidney & Upper Urinary Tract: Masses & Cysts

 Computed Tomography
   !    Current gold standard
   !    Non-contrast scan, then scan with
        intravenous contrast
         !  Enhancement = Hounsfield units

            (density) increase by > 10 with
            contrast
   !    3 to 5 mm maximum cut width
   !    Spiral CT - single breath hold
         !  Minimize motion artifact

         !  Exact duplication of cuts
Computed Tomography




Source Undetermined



                      Simple Cyst
Computed Tomography




 Source Undetermined


                       Complex Cyst
Source Undetermined




  Renal Cell Carcinoma
Kidney & Upper Urinary Tract: Masses & Cysts
Solid, Enhancing Renal Mass on CT is
 RCC until Proven Otherwise
  !    Other possibilities
        !  Oncocytoma

             –  Benign, but indistinguishable from
                RCC on imaging
        !  Angiomyolipoma

             –  Benign, but can bleed if large
             –  Usually diagnosed by imaging fat
        !  Inflammatory mass

             –  History of febrile illness
        !  Lymphoma

             –  Malignant, but no surgery
Source Undetermined

                      Oncocytoma ?
Angiomyolipoma


Source Undetermined
Renal Abscess




Source Undetermined
Renal Lymphoma




Source Undetermined
Kidney & Upper Urinary Tract: Masses & Cysts

 Magnetic Resonance Imaging
   !    Currently no advantage over CT except
        in certain situations
        !    Allergy to contrast material
        !    Elevated creatinine
        !    Distinguish wall in some cysts
        !    Detection of venous tumor thrombus
             in RCC (has replaced invasive
             venography)
Magnetic Resonance Imaging




 Source Undetermined


                       Thick Cyst Wall
Magnetic
Resonance
Imaging



Tumor
Thrombus
in Vena
Cava


            Source Undetermined
Kidney & Upper Urinary Tract: Masses & Cysts

 Sensitivity for Diagnosis of
  RCC < 3 cm

   !    Intravenous urography   - 67%

   !    Ultrasonography         - 79%


   !    Computed tomography     - 94%
Kidney & Upper Urinary Tract: Masses & Cysts

Evaluation of Suspected RCC
  !    Initial imaging study (often IVU or US, either
       incidentally or for workup of hematuria or
       other signs / symptoms)
  !    CT or MRI for local assessment
        !    Define lesion
        !    Assess nodes, vein, other organs
  !    Staging
        !    CXR, Bloods, + Bone Scan and others
Kidney & Upper Urinary Tract: Masses & Cysts

Staging and Management of RCC
 !    Stage I
       !    Tumor < 7 cm limited to kidney (T1)
       !    no LN+ or metastases
       "  Radical   or Partial Nephrectomy
 !    Stage II
       !    Tumor > 7 cm limited to kidney (T2)
       !    No LN+ or metastases
       "  Radical   Nephrectomy
Kidney & Upper Urinary Tract: Masses & Cysts

Staging and Management of RCC
 !    Stage III
       !    Tumor into vein, fat, or adrenal
       !    Or one single LN+
       "  Radical   Nephrectomy
 !    Stage IV
       !    Tumor beyond Gerota s fascia (T4)
       !    Or > 1 LN+ Or metastases
       "  Systemic    Therapy (Chemo, Immuno)
Kidney & Upper Urinary Tract: Masses & Cysts


 Prognosis of RCC
                            5 year survival
   !    Stage I                  ~90%
   !    Stage II                 ~80%
   !    Stage III                ~40 - 60%
   !    Stage IV                 ~10%
Kidney & Upper Urinary Tract: Masses & Cysts

Case 6: Autosomal Dominant Polycystic
 Kidney Disease (ADPKD)
   !    37 year old woman
   !    No recent medical care
   !    Left flank fullness
   !    Adopted, unknown family history
   !    PE
         !  Mass in left flank

         !  BP 170/100
Kidney & Upper Urinary Tract: Masses & Cysts

Case 6: Autosomal Dominant Polycystic
 Kidney Disease (ADPKD)
  !    Middle-aged - usually diagnosed in third
       decade
  !     Fullness - HUGE bilateral cysts,
       symptomatic in ~15%
  !    Over 50% have family history
  !    Hypertension - almost always, given
       enough time
Kidney & Upper Urinary Tract: Masses & Cysts

ADPKD
 !    Autosomal dominant inheritance
       !    85% from PKD1 mutation (16q13)
       !    15% from PKD2 mutation (4q21-23)
 !    Virtually 100% penetrance
 !    Incidence
       !    1 / 1000 live births
       !    6000 new cases annually
 !    Prevalence ~ 200,000
Kidney & Upper Urinary Tract: Masses & Cysts

ADPKD
 !    Epithelial proliferation in renal tube ! renal
      tubule become cyst ! as cyst grows it
      compresses renal parenchyma
 !    < 1% tubules become cysts
 !    Also hepatic, pancreatic and splenic cysts,
      and cerebral aneurysms
 !    Hypertension
 !    Renal failure - most but not all, usually in
      5th decade
ADPKD




Source Undetermined
Source Undetermined
Kidney & Upper Urinary Tract: Masses & Cysts

Other Cystic Diseases of the Kidney
  !    Simple cysts
        !    In population over age 50
              –  50%   pathologically, 33% by CT
        !    Single or multiple
  !    Simple cyst complicated by hemorrhage or
       infection ( Complex cyst )
  !    Acquired cystic kidney disease (ACKD)
        !    40% of dialysis patients by 3 years
        !    Controversial increase in RCC
ACKD




Source Undetermined
Kidney & Upper Urinary Tract: Masses & Cysts

 Evaluation of Renal Cysts
   !    Simple cysts definable with US
         !  No further work-up needed

   !    ADPKD, ACKD
         !  Definable by history and PE

   !     Complex Cyst
         !  Simple cyst complicated by infection

            or hemorrhage
         !  Cystic renal cancer

         !  Diagnostic dilemma, surgery often

            required
Additional Source Information
                           for more information see: http://open.umich.edu/wiki/CitationPolicy

Slide 28: Stuart Wolf
Slide 30: Gray s Anatomy
Slide 31: Gray s Anatomy
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10.08.08: Diseases of the Kidney Upper Urinary Tract

  • 1. Author(s): J. Stuart Wolf, Jr., M.D., 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution–Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  • 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  • 3. Kidney and Upper Urinary Tract J. Stuart Wolf, Jr., M.D. Professor of Urology Fall 2008
  • 4. Michigan Urology Center University of Michigan Ann Arbor, MI
  • 5. Kidney and Upper Urinary Tract Syllabus !  If I show you graphics that are NOT in your syllabus !  Then they are NOT critical for the test !  They are to familiarize you with Urologic operative techniques, for their interest rather than for testing purposes !  Radiography will be on test, but not the actual images
  • 6. Kidney and Upper Urinary Tract Objectives !  Appreciate importance, evaluation, and differential diagnosis of hematuria !  Gain basic understanding of major disease processes of kidney and upper tract !  Obstruction !  Calculi !  Infection !  Renal masses and cysts
  • 7. Kidney and Upper Urinary Tract Clinically-Oriented Lecture Hematuria Evaluation and Differential Case presentations of representative entities
  • 8. Hematuria Hematuria !  Definition !  > 3 RBC / hpf in urinary sediment !  Dipstick is screening test only !  Dipstick is 95 % sensitive, but only about ~ 80% specific !  In population with 10% hematuria, PPV of Dipstick is only 35% !  Positive Dipstick indicates hematuria ONLY when confirmed by microscopy of > 3 RBC / hpf
  • 9. Hematuria Hematuria !  Additional Characterization !  Gross (grossly visible) or microscopic? –  Gross more likely significant !  If gross, is it initial (urethra), terminal (bladder neck or prostate), or total (interior of bladder or upper tract)
  • 10. Hematuria Evaluation 1: Examine Urine !  In women, get cath. UA if > 1 squamous cell / hpf (vaginal contamination) !  Is color red but dipstick - ? " Consider phenolphthalein, rhodamine B, others !  Is dipstick + but no RBC present? " Beware if specific gravity < 1.008 (RBC may have been there, but lysed) " Usually false positive test " Unfortunately, a common referral
  • 11. Hematuria Evaluation 1: Examine Urine !  Is there pyuria or bacteruria? " Probable infection (any GU site) !  Is there proteinuria (> 2 + on dipstick), or are there dysmorphic RBCs or RBC casts? " Probable glomerulonephritis
  • 12. Hematuria Evaluation 2: History and Physical !  Flank Pain "  Stone !  Dysuria, bladder irritability "  Bladder or prostate infection !  Sickle cell, diabetes "  Papillary necrosis !  Family or personal history of calculi, PCKD, other GU / Neph diseases "  Possible familial trait
  • 13. Hematuria Evaluation 2: History and Physical !  Trauma, or intense physical activity "  May be cause of hematuria !  Tobacco use, occupational chemical exposure (aromatic dyes) "  Risk for renal and urothelial cancers
  • 14. Hematuria Evaluation 2: History and Physical !  Visible blood at urethral meatus "  Urethral source !  Fever, CVAT "  Pyelonephritis !  Prostate exam "  Prostatitis, Prostate cancer !  Pelvic Exam "  Urethral, vaginal, or labial lesions
  • 15. Hematuria Evaluation 3: Labs and Procedures !  Formal urinalysis with microscopic examination !  Urine culture !  If infection is DOCUMENTED, then can omit rest of work-up if hematuria clears with antibiotics !  IVU versus KUB + US versus CT !  +/- Urine cytology !  +/- Serum electrolytes and creatinine !  Cystoscopy
  • 16. Hematuria Diagnostic Categories !  Infection !  Calculi !  Cancer !  Benign neoplasms / lesions !  Other obstruction !  Trauma / exertional hematuria !  Medical renal disease !  Blood dyscrasia / anticoagulation !  Benign familial hematuria
  • 17. Hematuria Infection !  Kidney !  Pyelonephritis - parenchyma !  Pyonephrosis - pus in collecting system !  Renal abscess - pus pocket in parenchyma
  • 18. Hematuria Infection !  Bladder !  Bacterial cystitis !  Prostate !  Bacterial prostatitis !  Urethra !  Infectious urethritis
  • 19. Hematuria Calculi !  Kidney !  Obstructive vs. Non-obstructive !  Simple vs. Staghorn !  Ureter !  Obstructive vs. Non-obstructive !  Bladder
  • 20. Hematuria Cancer !  Kidney !  Renal cell carcinoma, other !  Upper collecting system !  Urothelial, other !  Bladder !  Urothelial, other !  Urethra !  Squamous cell, other !  Prostate !  Adenocarcinoma, other
  • 21. Hematuria Benign Neoplasms / Lesions !  Kidney !  Simple cysts !  Cystic renal diseases !  Angiomyolipoma, other neoplasms !  Ureter !  Hemangioma, other !  Bladder !  Endometrioma, other !  Urethra !  Condyloma, other
  • 22. Hematuria Other Obstructions !  Ureter !  Ureteropelvic junction (UPJ) !  Intrinsic strictures !  Extrinsic obstruction !  Bladder !  Bladder outlet obstruction (BOO) –  Benign prostatic hyperplasia (BPH) –  Other !  Urethra –  Strictures, other
  • 23. Hematuria Trauma / Exertional Hematuria !  Cannot be assumed to be cause Medical Renal Disease !  Previous Nephrology lecture Blood Dyscrasia / Anticoagulation !  Cannot be assumed to be cause Benign Familial Hematuria !  Microscopic only, negative work-up
  • 24. Kidney & Upper Urinary Tract Kidney, Intra-renal Collecting System, and Ureter !  Topics covered (case presentations) !  Ureteral obstruction (UPJO) !  Calculi (ureteral, renal) !  Infection (pyelonephritis) !  Cancer (renal cell carcinoma) !  Renal cystic disease (ADPKD)
  • 25. Kidney & Upper Urinary Tract: Obstruction Case 1: Ureteropelvic Junction Obstruction (UPJO) !  24 year old woman !  Long history of intermittent left flank pain, recently worsening !  Not during sleep !  Especially notices after fluid intake, or even more after drinking alcohol !  No significant medical history
  • 26. Kidney & Upper Urinary Tract: Obstruction Case 1: Ureteropelvic Junction Obstruction (UPJO) !  Young age - diagnosed mostly in children, variable after that !  Intermittent symptoms - typical of adult presentation !  Pain increased with fluid intake !  Classic for UPJO !  Flow-dependent obstruction (like a slow but not-yet clogged drain)
  • 27. Kidney & Upper Urinary Tract: Obstruction Anatomy of Kidney and Upper Urinary Tract !  Paired Kidneys !  Urine from collecting tubules that terminate in papillae drain into: !  Calyces, that coalesce into !  Infundibula, which drain into !  Renal Pelvis !  Travels down ureter (peristalsis)
  • 28. Kidney & Upper Urinary Tract: Obstruction Calyx Renal Pelvis Infundibulum J.S. Wolf
  • 29. Kidney & Upper Urinary Tract: Obstruction Anatomy of Kidney and Upper Urinary Tract !  Tight spots prone to obstruction !  Ureteropelvic junction (UPJ) !  Mid-ureter as crosses iliac vessels (over sacrum on plain radiograph) !  Ureterovesical junction (UVJ) !  Of these, the UPJ most common site of congenital obstruction
  • 33. Kidney & Upper Urinary Tract: Obstruction Case 1: Ureteropelvic Junction Obstruction (UPJO) Evaluation !  Intravenous urogram !  Unilateral hydronephrosis and non- visualization of ureter !  Diuretic renal scintigraphy !  50% split renal function !  T 1/2 (time for ! of tracer to exit kidney) on symptomatic side > 100 minutes (normal < 10 minutes)
  • 34. Intravenous Urogram Left hydronephrosis and non- visualization of the ureter Source Undetermined
  • 35. Diuretic Renal Scintigraphy Source Undetermined Excretion from left kidney is delayed
  • 36. Kidney & Upper Urinary Tract: Obstruction Case 1: Ureteropelvic Junction Obstruction (UPJO) Treatment !  Percutaneous endopyelotomy !  A minimally-invasive alternative to formal pyeloplasty !  Nephro-ureteral stent capped off in 1 week, and removed in 6 weeks !  Complete resolution
  • 37. Kidney & Upper Urinary Tract: Obstruction Causes of UPJO !  Primary !  Histological disorganization –  excess longitudinal muscle fibers (loss of normal organization) –  increase in collagen –  attenuation of muscle bundles !  Crossing vessels, high insertion, kinks, bands !  Secondary !  Traumatic scar, iatrogenic scar, external compression (think cancer!)
  • 38. Kidney & Upper Urinary Tract: Obstruction Evaluation of UPJO !  Determine presence and degree of obstruction !  Is there obstruction, or just dilation? !  Complete or partial obstruction? !  Determine renal function !  If kidney not working well, may be little value in repairing !  Determine cause of obstruction
  • 39. Kidney & Upper Urinary Tract: Obstruction Dilation of the Urinary Tract !  Non-obstructive !  Ureteral reflux, prior obstruction, extra- renal pelvis, diuresis !  Stagnation may lead to infection and calculi, but usually innocuous !  Obstructive !  Increased resistance to urine flow that produces increased proximal pressure and subsequent loss of organ function !  Occasionally difficult to distinguish from non-obstructive
  • 40. Massive Vesico-ureteral Reflux on Cystogram Source Undetermined
  • 41. Kidney & Upper Urinary Tract: Obstruction Evaluation of UPJO !  Anatomic tests !  Intravenous urography !  Renal (surface) ultrasonography !  Computed tomography !  Endoluminal ultrasonography !  Functional tests !  Ultrasonography with resistive indices !  Diuretic renal scintigraphy !  Whitaker test
  • 42. Intravenous Urography Normal kidney Hydronephrosis Source Undetermined
  • 43. Renal Ultrasonography Hydronephrosis Source Undetermined
  • 44. Computed Tomography Can determine additional anatomy, including vessels crossing at UPJ Source Undetermined
  • 45. Computed Tomography Can determine additional anatomy, including vessels crossing at UPJ Source Undetermined
  • 46. Endoluminal Ultrasonography Can detect vessels crossing over UPJ, but requires retrograde catheterization Source Undetermined
  • 47. Ultrasonography with Resistive Indices (PSV - LDV) /PSV: Normal Diastolic flow velocity is preserved Source Undetermined
  • 48. Ultrasonography with Resistive Indices (PSV - LDV) /PSV: Obstructed Source Undetermined As resistance to blood flow increases, diastolic flow velocity decreases, and resistive index increases (R.I. > 0.70)
  • 49. Diuretic Renal Scintigraphy: most definitive non-invasive test T ! = Time for ! of radiotracer to be excreted from kidney after furosemide T ! = 5 minutes T ! = 25 minutes (normal < 10 min.) (obstructed > 15 min.) Sources Undetermined
  • 50. Whitaker Test: most definitive test Pressure in renal pelvis at set infusion rate through nephrostomy tube (> 15 mmHg at 15 cc/min infusion = obstruction) Source Undetermined
  • 51. Kidney & Upper Urinary Tract: Obstruction Treatment of UPJO Most !  Open pyeloplasty Invasive / Most Effective !  Laparoscopic pyeloplasty !  Percutaneous endopyelotomy !  Retrograde balloon dilation Least !  Retrograde endopyelotomy Invasive / Least !  Acucise® (cutting balloon) endopyelotomy Effective
  • 52. Break
  • 53. Kidney & Upper Urinary Tract: Calculi Case 2: Acutely Obstructing Distal Ureteral Calculus !  30 year old man !  Sudden onset of right flank pain !  Initial gross hematuria, but now clear !  No fevers and chills, but nausea !  Frequent urination !  Pain somewhat less after a few hours !  Restless, moving about !  Right flank, lower quadrant, and testicular pain / tenderness !  5 - 10 RBC / hpf on urinalysis
  • 54. Kidney & Upper Urinary Tract: Calculi Case 2: Acutely Obstructing Distal Ureteral Calculus !  Sudden onset pain - c/w renal colic !  Urine cleared - suggests obstruction !  Nausea - very common with renal colic !  Freq. urination - irritation by distal calculi !  Pain decreased - forniceal rupture, decrease in pressure from renal hemodynamics !  Moving about - NOT peritonitis !  Flank to scrotum - expected radiation !  Urinalysis - RBCs in 85%
  • 55. Kidney & Upper Urinary Tract: Calculi Suspected Acute Ureteral Obstruction Differential Diagnosis !  Intrinsic !  Calculi, tumor, clot, edema !  Extrinsic !  Compression by tumor, lymph node !  Acute versus acute-on-chronic !  Calculi, or calculi impacted into partially- obstructing stricture? !  Clot, or clot on tumor?
  • 56. Kidney & Upper Urinary Tract: Calculi Suspected Acute Ureteral Obstruction Radiographic Evaluation !  KUB and Intravenous urography !  Anatomic picture, localize pathology !  Ultrasonography !  CT !  Non-contrast (stones) !  CT urogram (with contrast, like IVU) !  Retrograde pyelography !  Injection through catheter
  • 57. Intravenous This stone Urography is less dense than contrast material, so appears as filling defect Source Undetermined
  • 58. Intravenous Urography This stone is faintly radio- opaque … Source Undetermined
  • 59. Intravenous Urography … and is easier to identify when contrast material comes down to it Source Undetermined
  • 60. Kidney & Upper Urinary Tract: Calculi Spontaneous Passage of Ureteral Stones Width ProximalMiddle Distal 4 mm 20% 45% 55% 5 mm 6% 30% 45% 6 mm 0% 10% 25% 100% 50% 0% 1 2 3 4 5 6 7 8 9 10 J.S. Wolf
  • 61. Ultrasonography Hydronephrosis Source Undetermined
  • 62. (almost) all Computed Tomography stones dense on CT Source Undetermined
  • 63. Computed Tomography Source Undetermined Secondary signs of ureteral obstruction
  • 64. Computed Tomography Source Undetermined Secondary signs of ureteral obstruction
  • 65. Computed Urography Source Undetermined
  • 66. Intravenous Urography Irregular Filling Defect Source Undetermined
  • 67. Kidney & Upper Urinary Tract: Calculi If filling defect on contrast study … !  Neoplasm !  Urothelial neoplasm most common !  Blood clot !  Will resolve during follow-up !  Radio-lucent calculus (15%) !  Other 85% are calcium containing !  Refers to appearance on plain film (all typical stones are opaque on CT scan) !  Radio-lucent stones are usually uric acid (only medically dissolvable stone) !  Need to rule-out tumor!
  • 68. Kidney & Upper Urinary Tract: Calculi Case 3: Non-obstructing Renal Calculus !  65 year old man !  Microscopic hematuria !  Remote history of urolithiasis !  Mild prostatism !  Unremarkable PE except for prostatic enlargement !  Urinalysis - 10 RBC / hpf
  • 69. Plain Radiography Densely radio- opaque stones Source Undetermined
  • 70. Kidney & Upper Urinary Tract: Calculi Indications for Surgical Treatment of Urolithiasis !  Urinary tract infection !  Significant obstruction !  Pain refractory to oral medication !  Others !  Staghorn calculi - risk of urosepsis !  Long-standing ureteral calculi - eventual obstruction !  Occupational or lifestyle reasons
  • 71. Plain Radiography Staghorn Calculus Source Undetermined
  • 72. Kidney & Upper Urinary Tract: Calculi Surgical Treatment of Urolithiasis !  Open surgical / laparoscopic Most lithotomy Invasive / Most Effective !  Percutaneous nephrostolithotomy (Antegrade endoscopy) !  Ureteroscopy (Retrograde endoscopy) Least !  Extracorporeal shock wave Invasive / Least lithotripsy (SWL) Effective
  • 79. Kidney & Upper Urinary Tract: Calculi Parameters Determining Treatment of Urolithiasis !  Size !  Location !  Composition !  Medical Condition, Patient Preference, Physician Preference
  • 80. Kidney & Upper Urinary Tract: Calculi Size !  Small !  SWL !  Moderate !  Ureteroscopy !  Large !  Percutaneous nephrostolithotomy
  • 81. Kidney & Upper Urinary Tract: Calculi Location !  Distal Ureter !  Scope > SWL !  Middle Ureter !  Scope > SWL !  Proximal Ureter !  SWL > Scope ? !  Kidney !  SWL > Scope
  • 82. Computed Tomography Source Undetermined Distal aspect of UVJ, almost in bladder
  • 83. Computed Tomography Source Undetermined Huge bilateral renal calculi
  • 84. Kidney & Upper Urinary Tract: Calculi Composition !  Dense (Calcium oxalate monohydrate) !  Scope !  Fuzzy/ Faint (Calcium oxalate dihydrate, calcium phosphate, struvite) !  SWL !  Cystine !  Scope !  Uric Acid !  SWL
  • 85. Plain Radiography Densely radio- opaque stone Source Undetermined
  • 86. Plain Radiography Fuzzy radio- opaque stone Source Undetermined
  • 87. Kidney & Upper Urinary Tract: Pyelonephritis Case 4: Pyelonephritis !  29 year old woman !  Started with 3 days of dysuria (painful urination), urinary frequency / urgency !  Now temp 101.7º C, right flank pain !  History !  Occ previous UTI !  Recently married !  Limited sexual activity before marriage, now active !  PE - Right CVAT
  • 88. Kidney & Upper Urinary Tract: Pyelonephritis Case 4: Pyelonephritis !  Young woman - UTI is common !  Initial cystitis (infection ascends) common and suggest UTI !  Systemic symptoms - distinguishes upper from lower tract UTI !  Previous UTI - helps establish her characteristic symptoms of UTI !  Sexual activity - predisposing factor for UTI in women !  CVAT - renal involvement
  • 89. Kidney & Upper Urinary Tract: Pyelonephritis Acute Pyelonephritis !  Most common disease of the kidney !  Usually ascending infection !  Diagnosis by clinical findings and urine culture (85% are GNR; E. Coli) !  Imaging used to detect complications or to assess for predisposing factors !  Complications: papillary necrosis, pyonephrosis, abscess, sepsis !  Predisposing factors: obstruction, calculi, vesico-ureteral reflux
  • 90. Source Undetermined Lobar Nephronia
  • 91. Kidney & Upper Urinary Tract: Pyelonephritis Management of Acute Pyelonephritis !  Typical case - fever resolves within 48 hrs of starting antibiotics !  Oral abx in most !  Intravenous abx if very ill-appearing !  Debilitated patients at greater risk !  Diabetes mellitus !  Steroids !  Chronically ill !  Immuno-suppressed
  • 92. Kidney & Upper Urinary Tract: Pyelonephritis Management of Acute Pyelonephritis !  History of complications or lack of response to antibiotics "  US or CT for obstruction, calculi !  Upper tract obstruction with infection "  DRAINAGE (stent, percutaneous tube) !  Upper tract calculus with infection "  Treat acute infection, then calculus !  If child or recurrent "  US for scars "  Voiding cystogram for reflux
  • 93. Kidney & Upper Urinary Tract: Pyelonephritis Drainage procedures !  Percutaneous nephrostomy tube Image of a percutaneous nephrostomy tube removed !  Ureteral stent Hildpeyi, wikimedia commons
  • 94. Break
  • 95. Kidney & Upper Urinary Tract: Masses & Cysts Case 5: Renal Cell Carcinoma (RCC) !  64 year old man !  Gross hematuria !  Flank pain !  History !  66 pack-year smoker !  PE !  Fullness in right flank
  • 96. Kidney & Upper Urinary Tract: Masses & Cysts Case 5: Renal Cell Carcinoma (RCC) !  Older man - peak in 6th decade, 3:1 M:F overall !  Hematuria - most common presenting sign !  Flank pain and flank mass - along with hematuria, the classic triad !  Smoking - major acquired risk factor
  • 97. Kidney & Upper Urinary Tract: Masses & Cysts Demographics of RCC !  Incidence: 12.8 per 100,000 ( 00 - 04) !  Mortality: 4.2 per 100,000 ( 00 - 04) !  estimated 51,190 new cases in 2007 (~2% of adult malignancies) !  estimated 12,890 deaths in 2007 !  Lifetime Risk (M / F) !  Risk of occurrence - 1.71 / 1.01 % !  Risk of death - 0.59 / 0.35 % SEER Cancer Statistics
  • 98. Kidney & Upper Urinary Tract: Masses & Cysts Risk factors for RCC !  Cigarettes !  Obesity !  Hypertension !  Occupational exposures !  Dialysis !  Hereditary !  von Hippel-Lindau disease !  Tuberous Sclerosis
  • 99. Kidney & Upper Urinary Tract: Masses & Cysts Pathology of RCC !  Proximal tubular cell neoplasm !  Often venous involvement !  Hemorrhagic, necrotic, cystic, and calcified components common !  Metastasize most commonly to lung, liver, bone, adrenal, and contralateral kidney
  • 100. Kidney & Upper Urinary Tract: Masses & Cysts Common Renal Tumors Pathology Malignant? Relative % Renal Cell Ca. Yes 85% Urothelial Ca. Yes 5% Oncocytoma No 5% Other Most not 5%
  • 101. Kidney & Upper Urinary Tract: Masses & Cysts Histology !  Most Renal Cell Carcinomas have Clear cell histology !  Lipids (dissolve out during slide processing) and glycogen !  Fuhrman grading (1 to 4) –  1 = well differentiated –  4 = poorly differentiated
  • 102. Kidney & Upper Urinary Tract: Masses & Cysts Genetics !  Most renal cell carcinomas are sporadic !  Are associated with several syndromes, the most common of which is Von- Hippel Lindau syndrome !  Autosomal dominant !  Cerebellar and retinal vascular tumors !  Adrenal and renal tumors (inc cysts)
  • 103. Kidney & Upper Urinary Tract: Masses & Cysts Genetics !  Von-Hippel Lindau syndrome !  Autosomal dominant !  Mutation in VHL tumor suppressor gene: 3p25-26 !  95% of sporadic clear cell renal cell carcinomas have VHL mutation !  One of the strongest associations among solid tumors !  Opportunities for gene therapy
  • 104. Kidney & Upper Urinary Tract: Masses & Cysts Symptoms / Signs of RCC !  Hematuria (29 – 60%) !  Flank pain (14 – 51%) !  Flank mass (21 – 47%) !  All 3 = Classic triad !  Present in < 10% !  Usually signifies advanced disease
  • 105. Kidney & Upper Urinary Tract: Masses & Cysts Paraneoplastic Syndromes !  ESR elevation !  Calcium elevation !  Polycythemia !  Anemia !  Thrombophlebitis !  Hyperinsulinism !  LFT elevation
  • 106. Kidney & Upper Urinary Tract: Masses & Cysts Central Role of Imaging Simple Cyst Benign Indeterminate Cyst ? Solid Mass Malignant
  • 107. Kidney & Upper Urinary Tract: Masses & Cysts Stage Migration of RCC due to more frequent imaging !  1970 s !  4% of RCC < 3 cm !  32% presented with metastases !  1980 s !  25 - 40% were incidental finding !  25% of RCC < 3 cm !  17% presented with metastases !  1990 s !  60% were incidental finding
  • 108. Kidney & Upper Urinary Tract: Masses & Cysts Imaging Modalities !  Intravenous Urography (IVU, IVP) !  Ultrasonography (US) !  Computed Tomography (CT) !  Magnetic Resonance Imaging (MRI)
  • 109. Kidney & Upper Urinary Tract: Masses & Cysts Intravenous Urography !  Typical upper tract imaging for hematuria work-up !  Excellent visualization of collecting system !  Renal mass or cyst causes displacement of surrounding organ or deformation of outline !  Screening study only !  If renal mass / cyst suspected, further imaging is required
  • 110. Intravenous Urography Mass Effect in kidney Source Undetermined
  • 111. Kidney & Upper Urinary Tract: Masses & Cysts Ultrasonography !  Usual follow-up to IVU suspicious for renal mass / cyst !  No ionizing radiation !  Non-invasive !  Operator dependent !  Reliably identifies simple cyst (85% of renal mass / cysts) !  If NOT a simple cyst !  Cross-sectional imaging
  • 112. Ultrasonography Simple Cyst Source Undetermined
  • 113. Kidney & Upper Urinary Tract: Masses & Cysts Sonographic Characteristics !  Anechoic with enhanced through transmission !  Simple cyst !  Echogenic with acoustic shadowing !  Stone or other calcification !  Iso / hypoechoic mass !  Solid mass
  • 114. Ultrasonography Renal Stone Source Undetermined
  • 117. Kidney & Upper Urinary Tract: Masses & Cysts Computed Tomography !  Current gold standard !  Non-contrast scan, then scan with intravenous contrast !  Enhancement = Hounsfield units (density) increase by > 10 with contrast !  3 to 5 mm maximum cut width !  Spiral CT - single breath hold !  Minimize motion artifact !  Exact duplication of cuts
  • 119. Computed Tomography Source Undetermined Complex Cyst
  • 120. Source Undetermined Renal Cell Carcinoma
  • 121. Kidney & Upper Urinary Tract: Masses & Cysts Solid, Enhancing Renal Mass on CT is RCC until Proven Otherwise !  Other possibilities !  Oncocytoma –  Benign, but indistinguishable from RCC on imaging !  Angiomyolipoma –  Benign, but can bleed if large –  Usually diagnosed by imaging fat !  Inflammatory mass –  History of febrile illness !  Lymphoma –  Malignant, but no surgery
  • 122. Source Undetermined Oncocytoma ?
  • 126. Kidney & Upper Urinary Tract: Masses & Cysts Magnetic Resonance Imaging !  Currently no advantage over CT except in certain situations !  Allergy to contrast material !  Elevated creatinine !  Distinguish wall in some cysts !  Detection of venous tumor thrombus in RCC (has replaced invasive venography)
  • 127. Magnetic Resonance Imaging Source Undetermined Thick Cyst Wall
  • 129. Kidney & Upper Urinary Tract: Masses & Cysts Sensitivity for Diagnosis of RCC < 3 cm !  Intravenous urography - 67% !  Ultrasonography - 79% !  Computed tomography - 94%
  • 130. Kidney & Upper Urinary Tract: Masses & Cysts Evaluation of Suspected RCC !  Initial imaging study (often IVU or US, either incidentally or for workup of hematuria or other signs / symptoms) !  CT or MRI for local assessment !  Define lesion !  Assess nodes, vein, other organs !  Staging !  CXR, Bloods, + Bone Scan and others
  • 131. Kidney & Upper Urinary Tract: Masses & Cysts Staging and Management of RCC !  Stage I !  Tumor < 7 cm limited to kidney (T1) !  no LN+ or metastases "  Radical or Partial Nephrectomy !  Stage II !  Tumor > 7 cm limited to kidney (T2) !  No LN+ or metastases "  Radical Nephrectomy
  • 132. Kidney & Upper Urinary Tract: Masses & Cysts Staging and Management of RCC !  Stage III !  Tumor into vein, fat, or adrenal !  Or one single LN+ "  Radical Nephrectomy !  Stage IV !  Tumor beyond Gerota s fascia (T4) !  Or > 1 LN+ Or metastases "  Systemic Therapy (Chemo, Immuno)
  • 133. Kidney & Upper Urinary Tract: Masses & Cysts Prognosis of RCC 5 year survival !  Stage I ~90% !  Stage II ~80% !  Stage III ~40 - 60% !  Stage IV ~10%
  • 134. Kidney & Upper Urinary Tract: Masses & Cysts Case 6: Autosomal Dominant Polycystic Kidney Disease (ADPKD) !  37 year old woman !  No recent medical care !  Left flank fullness !  Adopted, unknown family history !  PE !  Mass in left flank !  BP 170/100
  • 135. Kidney & Upper Urinary Tract: Masses & Cysts Case 6: Autosomal Dominant Polycystic Kidney Disease (ADPKD) !  Middle-aged - usually diagnosed in third decade !  Fullness - HUGE bilateral cysts, symptomatic in ~15% !  Over 50% have family history !  Hypertension - almost always, given enough time
  • 136. Kidney & Upper Urinary Tract: Masses & Cysts ADPKD !  Autosomal dominant inheritance !  85% from PKD1 mutation (16q13) !  15% from PKD2 mutation (4q21-23) !  Virtually 100% penetrance !  Incidence !  1 / 1000 live births !  6000 new cases annually !  Prevalence ~ 200,000
  • 137. Kidney & Upper Urinary Tract: Masses & Cysts ADPKD !  Epithelial proliferation in renal tube ! renal tubule become cyst ! as cyst grows it compresses renal parenchyma !  < 1% tubules become cysts !  Also hepatic, pancreatic and splenic cysts, and cerebral aneurysms !  Hypertension !  Renal failure - most but not all, usually in 5th decade
  • 140. Kidney & Upper Urinary Tract: Masses & Cysts Other Cystic Diseases of the Kidney !  Simple cysts !  In population over age 50 –  50% pathologically, 33% by CT !  Single or multiple !  Simple cyst complicated by hemorrhage or infection ( Complex cyst ) !  Acquired cystic kidney disease (ACKD) !  40% of dialysis patients by 3 years !  Controversial increase in RCC
  • 142. Kidney & Upper Urinary Tract: Masses & Cysts Evaluation of Renal Cysts !  Simple cysts definable with US !  No further work-up needed !  ADPKD, ACKD !  Definable by history and PE !  Complex Cyst !  Simple cyst complicated by infection or hemorrhage !  Cystic renal cancer !  Diagnostic dilemma, surgery often required
  • 143. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 28: Stuart Wolf Slide 30: Gray s Anatomy Slide 31: Gray s Anatomy Slide 34: Source Undetermined Slide 35: Source Undetermined Slide 40: Source Undetermined Slide 42: Source Undetermined Slide 43: Source Undetermined Slide 44: Source Undetermined Slide 45: Source Undetermined Slide 46: Source Undetermined Slide 47: Source Undetermined Slide 48: Source Undetermined Slide 49: Source Undetermined Slide 50: Source Undetermined Slide 57: Source Undetermined Slide 58: Source Undetermined Slide 59: Source Undetermined Slide 60: Stuart Wolf Slide 61: Source Undetermined Slide 62: Source Undetermined Slide 63: Source Undetermined Slide 64: Source Undetermined Slide 65: Source Undetermined Slide 66: Source Undetermined Slide 69: Source Undetermined Slide 71: Source Undetermined
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