CONGENITAL ANOMALIES & TRAUMA OF THE GENITOURINARY TRACT DEPARTMENT OF UROLOGY IAŞI – 2013.

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CONGENITAL ANOMALIES & CONGENITAL ANOMALIES & TRAUMA OF THE TRAUMA OF THE GENITOURINARY TRACT GENITOURINARY TRACT DEPARTMENT OF UROLOGY IAŞI – 2013

Transcript of CONGENITAL ANOMALIES & TRAUMA OF THE GENITOURINARY TRACT DEPARTMENT OF UROLOGY IAŞI – 2013.

Page 1: CONGENITAL ANOMALIES & TRAUMA OF THE GENITOURINARY TRACT DEPARTMENT OF UROLOGY IAŞI – 2013.

CONGENITAL CONGENITAL ANOMALIES & TRAUMA ANOMALIES & TRAUMA OF THE OF THE GENITOURINARY TRACTGENITOURINARY TRACT

DEPARTMENT OF UROLOGY IAŞI – 2013

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

more frequently than in any other organ many cause impairment of renal function association with other renal and extrarenal congenital anomalies

AGENESIS bilateral – extremely rare; children do not survive; prenatal

suspicion – oligohydramnios (US) unilateral – no symptoms; cystoscopy – ureteral ridge absent, no

orifice visualized; definitive diagnosis – isotope studies, US, CTHYPOPLASIA

small kidney, smtm dysplastic; the other maybe larger than normal

observed in infants with fetal alcohol syndrome or in utero cocaine exposure

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

differentiation – acquired atrophy (atrophic pyelonephritis, VUR, stenosis of the renal artery)

associated with hypertension nephrectomyADULT POLYCYSTIC KIDNEY DISEASE

autosomal dominant hereditary condition; almost always bilateral (95%)

in infants – autosomal recessive disease; short life expectancy cysts of the liver, spleen and pancreasEtiology & Pathogenesis defects in the development of the collecting and uriniferous

tubules and in the mechanism of their joining blind secretory tubules connected to functioning glomeruli cysts enlarge & compress adjacent parenchyma destroy it by ischemia and occlude normal tubules progressive functional impairment

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

Symptoms pain (drag on the vascular pedicles by the

heavy kidneys, obstruction, infection,hemorrhage into a cyst)

gross or microscopic total hematuria colic (blood clots or stones) abdominal mass infection (chills, fever, renal pain) renal insufficiency (headache, nausea,

vomiting, weakness, loss of weight)Signs palpable kidneys (nodular, tender if infected) hypertension ( 60-70%) fever (pyelonephritis or infected cysts)

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

uremia (anemia, loss of weight)Laboratory anemia (chronic loss of blood or hematopoietic depression of

uremia) proteinuria and hematuria; pyuria and bacteriuria progressive creatinine clearanceUS – multiple transsonic images, large renal sizeIVU enlarged renal shadows on a plain film bizarre (spider deformity) caliceal pattern (broadened, flattened,

enlarged, curved)CT – extremely accurate (95%) for diagnosis – multiple thin-walled

cysts filled with fluid, large renal size

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

Differential Diagnosis bilateral hydronephrosis bilateral renal tumor von Hippel-Lindau disease (angiomatous cerebellar cyst, angiomatosis of

the retina, tumors or cysts of the pancreas, multiple bilateral cysts or adenocarcinomas of both kidneys)

tuberous sclerosis (convulsive seizures, mental retardation, adenoma sebaceum, hamartomatous tumors of the skin, brain, retinas, bones, liver, heart, and kidneys)

simple cystComplications pyelonephritis infection of cysts severe gross hematuria

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

Treatment General Measures: low-protein diet (0.5-0.75 g/kg/d), fluids (≥ 3 L/d),

reasonable physical activity, treatment of uremia (hemodialysis), control of hypertension

Surgery: a large cyst compressing the upper ureter (obstruction and impairment of renal function) resected or aspirated; renal insufficiency chronic dialysis or renal transplantation

Treatment of Complications: pyelonephritis; infection of cysts surgical or percutaneous drainage; severe bleeding nephrectomy or selective embolization

Prognosis children – very poor clinical signs and symptoms after age 35-40 – more favorable

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

SIMPLE (SOLITARY) CYST usually unilateral and single, but may be

multiple and multilocular; more rarely,bilateral

Etiology & Pathogenesis origin may be similar to that of polycystic

kidneys, but the lesion can be acquired(chronic dialysis)

as it grows compresses and maydestroy renal parenchyma; may compressthe ureter progressive hydronephrosis

spontaneous regression of cysts has occasionally been notedPathology 5% contain hemorrhagic fluid (1/2 have papillary cancers on their walls)

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

Clinical Findings Symptoms: pain in the flank or back, intermittent and dull; severe

pain (bleeding); mass in the abdomen; pain in the flank, malaise, and fever (infected cyst)

Signs: mass palpated or percussed; tenderness in the flank (infected cyst)

Laboratory: usually normal US – differentiates between a cyst and a solid mass; percutaneous

cyst aspiration CT – differentiates renal cyst and tumor (attenuation of cysts ≈ water,

density of tumors ≈ parenchyma; parenchyma more dense with contrast i.v., cyst unaffected)

Percutaneous Cyst Aspiration With Cystography: differentiation between cyst and tumor

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

Differential Diagnosis carcinoma of the kidney (walls of a simple cyst – cancerous degeneration) polycystic kidney disease, renal carbuncle, hydronephrosis extrarenal tumor (adrenal, mixed retroperitoneal sarcoma) echinococcal (hydatid) cyst of the kidney Complications (rare) – spontaneous infection, hemorrhage into the

cyst, hydronephrosis (cyst of the lower pole)Treatment follow-up with US; if no definitive diagnosis with US, CT or MRI

perc. needle aspiration (clear fluid benign cyst), cytologic evaluation, cystography; hemorrhagic fluid surgical exploration

complications: infected cyst intensive antimicrobial therapy + percutaneous or surgical drainage; hydronephrosis percutaneous puncture, aspiration & sclerotherapy

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

RENAL FUSION ≈ 1‰, the most common – horseshoe kidneyEtiology & Pathogenesis fusion of the 2 metanephroi occurs early in embryologic life

seldom ascend to the normal position (may remain in the pelvis); may derive its blood supply from many vessels (aorta, iliacs)

Pathology normal rotation cannot occur each pelvis lies on the anterior

surface ureter must ride over the isthmus (horseshoe kidney) or traverse the anterior surface (fused kidney) ureteral compression hydronephrosis

horseshoe kidney: isthmus joins the lower poles of each kidney; each renal mass lies lower than normal; axes of the masses are vertical or divergent upwards

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

Clinical findings Symptoms: no symptoms; ureteral obstruction; infection; calculus Signs: usually negative; abnormally placed renal mass (horseshoe

kidney – palpable mass over the lower lumbar spine [isthmus], crossed ectopy – mass in the flank or lower abdomen)

Laboratory: normal X-Ray: horseshoe kidney – axes of the kidneys parallel to the spine

on a plain film, isthmus can be identified; large soft-tissue mass in one flank w/o a renal shadow on the other side

IVU: horseshoe kidney – renal pelves lie on the anterior surfaces of the kidney masses, calyces in the lower pole that point medially and lie medial to the ureter; crossed renal ectopy with fusion – 2 pelves and 2 ureters (one ureter must cross the midline); cake or lump kidney (fused pelvis kidney) – may compress the dome of the bladder

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

Clinical findings CT – outlines the renal mass Retrograde urograms: show the position of theureters and pelves

(pelvic fused kidney) Renal scanning: delineates the renal mass and its contourDifferential Diagnosis - separate kidneys that fail to undergo normal

rotation, other abdominal massesComplications – ureteral obstruction, hydronephrosis, stone,

infection, dystocia due to a large fused kidney occupying the concavity of the sacrum

Treatment – no treatment unless obstruction or infection; drainage of a horseshoe kidney by dividing the isthmus; surgical resection

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

ECTOPIC KIDNEYSimple Ectopy low kidney on the proper side that failed to ascend normally (may

lie in the pelvis), blood supply from adjacent vessels, short ureter; prone to ureteral obstruction and infection pain or fever

may be palpable - differential diagnosis (cancer of the bowel, appendiceal abscess)

IVU – position of the kidney; no redundancy of the ureter (as with nephroptosis or acquired ectopy [displacement by large adrenal tumor])

treatment of obstruction and infectionCrossed Ectopy Without Fusion the kidney lies on the opposite side – US, angiography or CT for

diagnosis

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CONGENITAL – KIDNEYCONGENITAL – KIDNEY

ABNORMAL ROTATION IVU – abnormal position

MEDULLARY SPONGE KIDNEY congenital autosomal recessive defect – cystic dilatation of the

renal collecting tubules (usually bilateral, affecting all of the papillae)

urinary stasis in the tubules infection and calculi symptoms – from infection and stone formation diagnosis (IVU or CT): pelvis and calyces are normal, but dilated

(streaked) tubules (cystic dilatation); plain film – small, round calculi in the pyramidal regions (just beyond the calyces)

differential diagnosis: tuberculosis, healed papillary necrosis, nephrocalcinosis

terapy of the complications (pyelonephritis, renal calculi)

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CONGENITAL – URETERCONGENITAL – URETER

are common, may cause severe obstruction or may be asymptomatic and of no clinical significance

URETERAL ATRESIA ureter may be absent entirely or may end blindly after extending

only part of the way to the flank embryologically – failure of the ureteral bud to form from the

mesonephric duct or by an arrest in its development before it comes in contact with the metanephric blastema

atretic ureteral bud absent or multicystic, dysplastic kidney, (rarely associated with hypertension, infection or tumor); contralateral VUR is common (voiding cystourethrogram)

treatment – observation

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CONGENITAL – URETERCONGENITAL – URETER

DUPLICATION OF THE URETER one of the most common congenital malformations of the urinary

tract (0.9%); autosomal dominant; F>M; often bilateral incomplete (Y) type – caused by branching of the ureteral bud

before it reaches the metanephric blastema; disorders of peristalsis may occur near the point of union

complete type – 2 ureteral buds 2 totally separate ureters and 2 separate renal pelves; the ureter to the upper segment migrates farther, ending medial and inferior to the ureter draining the lower segment (Weigert-Meyer law) the ureter draining the upper segment may migrate too far caudally and become ectopic and obstructed; the ureter draining the lower segment may end laterally and have a short intravesical tunnel VUR

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CONGENITAL – URETERCONGENITAL – URETER

clinical findings – asymptomatic; persistent or recurrent infections; F – ureter to the upper pole may be ectopic, distal to the external sphincter or outside the urinary tract true incontinence + normal pattern of voiding; M – ectopic ureter is always proximal to the external sphincter (w/o incontinence)

IVU – duplication; occasionally, one segment of the kidney is not visualized, but there is displacement of the visualized calyces or ureter or discrepancy between the amount of renal parenchyma and the relatively small number of visualized calyces

voiding cystourethrogram – VUR or ureterocele US – hydronephrotic upper pole and dilated distal ureter; evaluate

parenchymal thickness and the presence of bladder anomalies

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CONGENITAL – URETERCONGENITAL – URETER

renal scanning (99mTc-DMSA) – estimating the degree of renal function in each renal segment

treatment lower grades of reflux medically higher grades of reflux surgically very poor renal function in one segment heminephrectomy to preserve renal parenchyma pyeloureterostomy,

ureteroureterostomy or ureteral reimplantationURETEROCELE

sacculation of the terminal portion of the ureter; it may be intravesical or ectopic (bladder neck or urethra)

F:M = 7:1; ≈ 10% are bilateral

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CONGENITAL – URETERCONGENITAL – URETER

delayed or incomplete canalization of the ureteral bud early prenatal obstruction and expansion of the ureteral bud; forms between the superficial and deep muscle layers of the trigone

clinical findings – infection; bladder outlet obstruction or incontinence; calculi can develop in the distal ureter

IVU, US – significant ureterohydronephrosis and a dysplastic segment of the upper pole of the kidney; voiding cystourethrography – reflux into the lower pole or contralateral ureter; renal scanning – estimating renal function

treatment – transurethral incision; heminephrectomy and ureterectomy, excision of the ureterocele, vesical reconstruction, ureteral reimplantation

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CONGENITAL – URETERCONGENITAL – URETER

ECTOPIC URETERAL ORIFICE most commonly in association with duplication of the ureter caused by a delay or failure of separation of the ureteral bud from

the mesonephric duct clinical picture: M – urinary tract infection or epididymitis (ureter

may drain directly into the vas deferens or seminal vesicle);F – continual dribbling despite normal voiding – pathognomonic (ureteral orifice in the urethra, vagina or perineum), infection (urgency and urge incontinence)

US, voiding cystourethrography, MRI, cystoscopy (hemitrigone, ectopic orifice may be visualized or demonstrated by retrograde catheterization) or laparoscopy

renal scanning – estimates relative renal function

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CONGENITAL – URETERCONGENITAL – URETER

OBSTRUCTION OF THE URETEROPELVIC JUNCTION (UPJ) the most common congenital abnormality of the ureter; M:F =

5:2; L:R = 5:2 bilateral obstruction – 10-15%, especially common in infants cause of obstruction (intrinsic or extrinsic): ureteral polyps and

valves (very rare), angulation and kink at the junction, true stenosis (rarely), thin-walled, hypoplastic proximal ureter (frequently), histologic and ultrastructural changes abnormal peristalsis through the UPJ and interference with pelvic emptying, high origin of the ureter from the renal pelvis, abnormal relationship of the UPJ to a lower-pole renal artery

clinical findings - most common symptoms: pain and vomiting; hematuria, urinary infection, calculi, trauma to the enlarged kidney or (rarely) hypertension

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CONGENITAL – URETERCONGENITAL – URETER

US – diagnosis; prenatal US – diagnosis in utero; in equivocal cases, diuretic renography or antegrade urography with pressure-flow studies; voiding cystourethrogram – findings in VUR may be similar

Therapy: symptomatic obstruction treated surgically; early surgery – kidneys with diminished function, massive hydronephrosis, infection or stones; nonoperative surveillance with close follow-up

procedures: dismembered pyeloureteroplasty (Anderson-Hynes), Foley Y-V plasty, pelvic flap procedures (Culp, Scardino)

endopyelotomy – antegrade, via a nephrostomy tract, or retrograde, using either a ureteroscope (for direct vision) or an Acucise balloon catheter with fluoroscopic visualization

laparoscopic pyeloplasty

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CONGENITAL – URETHRACONGENITAL – URETHRA

URETHRAL STRICTURE uncommon in infant boys (fossa navicularis and membranous

urethra) severe strictures may cause bladder damage

and hydronephrosis symptoms of obstruction or urinary infection

POSTERIOR URETHRAL VALVES the most common obstructive urethral lesions

in male infants and newborns treatment – destruction of the valves –

transurethral fulguration of the valves

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CONGENITAL – URETHRACONGENITAL – URETHRA

HYPOSPADIAS urethral meatus opens on the ventral side of the

penis proximal to the tip of the glans penis repair with foreskin island flaps/buccal mucosa

grafts and incised urethral plateEPISPADIAS

urethra opens on the dorsal aspect of thepenis; a distal groove extends from themeatus through the glans

surgery is required to correct theincontinence, remove the chordee tostraighten the penis, and extend the urethraout onto the glans penis

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CONGENITAL – TESTISCONGENITAL – TESTIS

CRYPTORCHIDISM incidence: 3.4-5.8% (at birth) & 1.8% (1 year – puberty) after

the first year spontaneous descent is unlikely to occur ectopic – descend normally through the external inguinal ring,

then misdirected to an extrascrotal position (superficial inguinal, perineal, prepenile, transverse scrotal, femoral or umbilical)

true cryptorchid – arrested in their normal line of descent (intraabdominal, intracanalicular or suprascrotal)

1/3 of cryptorchid cases are bilateral infertilityHistology and Endocrine Pathology reduced number of germ cells (2nd year, persists thereafter) impaired function of the hypothalamic-pituitary-gonadal axis

testosterone failure of testicular descent + failure of proliferation and maturation of germ cells

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CONGENITAL – TESTISCONGENITAL – TESTIS

the higher the testis location the worse its histology unilateral cryptorchidism is a bilateral disease contralateral

descended testis is abnormal – similar abnormalities, but to a lesser degree subfertility

Diagnosis every general pediatric examination in boys – examination of the

testicular position! US – high false-negative rate! (testis present despite negative

ultrasound) CT (irradiation!) & MRI selective diagnostic laparoscopy orchidopexy or orchiectomy

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CONGENITAL – TESTISCONGENITAL – TESTIS

Treatment early (8-12 months) risk of infertility, malignancy (10-46)

and testicular torsion hormonal treatment induction of testicular descent and

stimulation of germ cell maturation and proliferation hCG GnRH (Kryptokur) nasal spray 1.2 mg/d,28 d, followed by hCG

1,500 IU/wk, 3 wks LHRH analog (Buserelin) – nasal spray

early orchiopexy (≤ 1 year) postpubertal – orchiectomy

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INJURIES TO THE G-U INJURIES TO THE G-U TRACTTRACT

EMERGENCY DIAGNOSIS & MANAGEMENT 10% of all injuries initial assessment – control of hemorrhage and shock, along with

resuscitation (i.v. lines and urethral catheter – blood at the urethral meatus?)

history – detailed description of the accident (? gunshot wounds – type and caliber)

examination of abdomen and genitalia contusions or subcutaneous hematomas fractures of the lower ribs and/or the bony pelvis diffuse abdominal tenderness

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INJURIES TO THE G-U INJURIES TO THE G-U TRACTTRACT

SPECIAL EXAMINATIONSCatheterization and Assessment of Injury (Staging) catheterization – blood at the urethral meatus in men urethral

injury catheterization should not be attempted, but retrograde urethrography; no blood urethral catheter ? microscopic or gross hematuria

abdominal CT with contrast media – retroperitoneal hematoma, renal lacerations, urinary extravasation, renal arterial and venous injuries, intra-abdominal injuries (liver, spleen, pancreas, bowel)

retrograde cystography (≥ 300 mL) – ? bladder perforations retrograde urethrography (12 F/3 mL) – 20 mL

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INJURIES TO THE G-U INJURIES TO THE G-U TRACTTRACT

Catheterization and Assessment of Injury (Staging) arteriography – renal parenchymal and vascular injuries,

persistent bleeding from pelvic fractures embolization with Gelfoam or autologous clot

IVU – detect renal and ureteral injuryCystoscopy and Retrograde Uretero-Pyelography seldom necessaryAbdominal Sonography if CT not available

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INJURIES TO THE KIDNEY INJURIES TO THE KIDNEY

the most common injuries of the urinary system pathologic kidneys (hydronephrosis, malignant tumors etc.) are

more readily ruptured from mild trauma Etiology blunt trauma to the abdomen, flank or back (85%) rapid deceleration can cause major vascular injury gunshot and knife wounds penetrating injuries associated abdominal visceral injuries are common!Pathology & Classification early pathologic findings – grade

1 – renal contusion or bruising of the renal parenchyma microscopic hematuria

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INJURIES TO THE KIDNEY INJURIES TO THE KIDNEY

2 – renal parenchymal laceration into the cortex small perirenal hematoma

3 – renal parenchymal laceration extending through the cortex and into the medulla significant bleeding, large retroperitoneal hematoma

4 – renal parenchymal laceration extending into the collecting system; main renal artery thrombosis from blunt trauma, segmental renal vein or both; artery injury with contained bleeding

5 – multiple grade 4 parenchymal lacerations, renal pedicle avulsion or both; main renal vein or artery injury from penetrating trauma

late pathologic findings – urinoma, hydronephrosis, arteriovenous fistula, renal vascular hypertension

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INJURIES TO THE KIDNEY INJURIES TO THE KIDNEY

late pathologic findings – urinoma, hydronephrosis, arteriovenous fistula, renal vascular hypertension

Clinical Findings & Indications for Studies some cases of renal vascular injury (deceleration) are not

associated with hematuria imaging studies the degree of renal injury does not correspond to the degree of

hematuria gross hematuria or microscopic hematuria with shock (systolic BP

< 90 mm Hg) imaging studies symptoms – pain (flank or over the abdomen), hematuria,

abdominal distention, ileus, nausea and vomiting (retroperitoneal bleeding )

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INJURIES TO THE KIDNEY INJURIES TO THE KIDNEY signs – shock or signs of a large loss of blood (heavy

retroperitoneal bleeding), ecchymosis in the flank or upper quadrants of the abdomen, lower rib fractures, diffuse abdominal tenderness

"acute abdomen" – free blood in the peritoneal cavity palpable mass ≈ large retroperitoneal hematoma or urinary

extravasation (torn retroperitoneum free blood in the peritoneal cavity, but no palpable mass)

laboratory – microscopic or gross hematuria, anemia (acute or chronic)

staging systematic approach abdominal CT scan parenchymal lacerations, urinary

extravasation, extent of the retroperitoneal hematoma, nonviable tissue, injuries to surrounding organs

arteriography – major arterial and parenchymal injuries

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INJURIES TO THE KIDNEY INJURIES TO THE KIDNEY

Complications early – hemorrhage (persistent retroperitoneal bleeding or heavy

gross hematuria), urinary extravasation (urinoma) abscess formation & sepsis

late – hypertension, hydronephrosis, arteriovenous fistula, calculus formation, pyelonephritis, heavy late bleeding !

Treatment emergency measures – prompt treatment of shock and

hemorrhage, complete resuscitation and evaluation of associated injuries

surgical measures blunt trauma (< 5%) – persistent retroperitoneal bleeding,

urinary extravasation, nonviable renal parenchyma and renal pedicle injuries

penetrating injuries – surgically explored (associated organ injury)

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INJURIES TO THE KIDNEY INJURIES TO THE KIDNEY

complications retroperitoneal urinoma or perinephric abscess surgical

drainage malignant hypertension vascular repair or nephrectomy hydronephrosis surgical correction or nephrectomy

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INJURIES TO THE URETER INJURIES TO THE URETER

rare, during difficult pelvic surgical procedures, gunshot wounds, rapid deceleration accidents (avulsion of the ureter from the renal pelvis), endoscopic procedures (ureteroscopies, basket manipulation of ureteral calculi)

flank & abdominal pain, nausea, vomiting, ileus; vaginal or cutaneous fistula

imaging: IVU, CT scanTreatment – prompt repair (if stenting not feasible) immediate – ureteroureterostomy, transureteroureterostomy,

reimplantation into the bladder, autotransplantation of the kidney, bowel replacement of the ureter + stenting

late – percutaneous nephrostomy, then repair

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INJURIES TO THE BLADDER INJURIES TO THE BLADDER

occur most often from external force and are often associated with pelvic fractures

iatrogenic injury – gynecologic and surgical extensive pelvic procedures and transurethral operations

Pathogenesis & Pathology extraperitoneal: pelvic fractures extraperitoneal rupture

urine extravasation deep pelvic abscess intraperitoneal acute abdomen (peritonitis)Clinical findings KUB – pelvic fractures CT scan retrograde cystography

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INJURIES TO THE BLADDER INJURIES TO THE BLADDER

Treatment shock & hemorrhage treatment extraperitoneal – urethral catheter drainage (10 d); cystoraphy intraperitoneal – transperitoneal approach, cystoraphy, bladder &

peritoneal drainage

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INJURIES TO THE URETHRA INJURIES TO THE URETHRA

INJURIES TO THE POSTERIOR URETHRA pelvic fractures from blunt trauma the membranous urethra is

sheared from the prostatic apex acute retention of urine retrograde urethrogram treatment – suprapubic cystostomy, delayed urethral

reconstructionINJURIES TO THE ANTERIOR URETHRA

straddle injury, self- or iatrogenic instrumentation urethral bleeding ± retention of urine; retrograde urethrogram urethral contusion no instrumentation or urethral catheter urethral laceration suprapubic cystostomy, delayed retrograde

urethrography, no further instrumentation or urethral catheter or urethroplasty