Kidneys, Ureters and Urethra

Department of Urology
The First Affiliated Hospital of Jinan University
Jie CHEN, MD
Chief Physician
To recognise and understand
– The management of open and closed trauma to the kidney and
ureter
– The etiology, presentation and surgical management of
obstruction to the upper urinary tract
– The pathophysiology of renal stone formation
– The management of urinary tract calculi
– The management of sepsis in the upper uriary tract
– The management of urethral trauma and urethral stricture
Contents
I. Urinary stone disease
II. Renal trauma
III. Urethral trauma
Topic 1st

I. Urinary stone disease

II. Renal trauma
III. Urethral trauma
Incidence
❏ 10% of population
❏ male:female = 4:3 to 3:1
• 50% chance of recurrence by 5 years
• peak incidence 30-50 years of age (50%)
1. Incidence
Urinary calculi are the most common diseases.
– In the US
 1-4/1000 annual incidence
 5-12% lifetime incidence

 2-10% of the population

– In China
 20-30% of hospitalized urological patients
 Higher incidence Guangdong province

Stone recurrence rates -- 50% within 5 years

2. Etiology
Etiology is complex and remains speculative

Dehydration
Hyperpara-
Obstruction
thyroidism

Prolonged
Infection Calculi immobilisation

Dietary Urinary
imbalance citrate
Randall’s
plaque
3. Stone Pathogenesis
 factors promoting stone formation
 stasis(hydronephrosis 肾盂积水 , congenital
abnormality)
 medullary sponge kidney 髓质海绵肾

 infection (struvite stones 鸟粪石 )

 Hypercalciuria 高钙尿症
 increased oxalate 草酸盐

 increased uric acid

 3. Stone Pathogenesis
 loss of inhibitory factors
 Magnesium 镁 (forms soluble complex with
oxalate)
 Citrate 柠檬酸盐 (forms soluble complex with
calcium)
 Pyrophosphate 焦磷酸盐

 glycoprotein
 4. Type of renal calculi 肾结石

calcium oxalate
5% 2%
13% calcium phosphate

magnesium ammonium
20% 60% phosphate
uric acid

cystine

About 80% of calculi in the USA are composed of Ca, mainly calcium oxalate; 5% are uric acid; 2%
are cystine; and the remainder are magnesium ammonium phosphate (or infection calculi). About 5%
of patients who form Ca calculi have primary hyperparathyroidism.
Type of renal calculi
 Radiodensities in air (to
improve contrast) of five
human calculi.
A: calcium oxalate;
B: calcium phosphate;
C: uric acid;
D: cystine;
E: magnesium ammonium
phosphate.
 Note that only the uric
acid calculus is truly
radiolucent.
5. Pathophysiology of urinary calculi
 The urinary calculi are formed in the kidneys
or the bladder.
 They may stay at the location or move down to
ureters or urethra, then cause:
– Acute or chronic obstruction,
– Infection
– Hydronephrosis
– Renal dysfunction.
1) Impaction of
ureteral输尿管的

calculi
2) Pathophysiology of urinary calculi
 Pathogenesis of unilateral
hydronephrosis.
– Progressive changes in
ureter and kidney secondary
to obstructing calculus.
– As the right kidney
undergoes gradual
destruction, the left kidney
gradually enlarges.
6. Clinical features
 Silent calculus
 Pain
 flank pain from renal capsular distension (non-colicky)
 severe waxing and waning （消长变化） pain radiating from flank
to groin, testis, or tip of penis, due to stretching of collecting
system or ureter (ureteral colic)

 Haematuria
– Pyuria 脓尿

 recurrent infection or pyonephrosis ( 肾积脓 )

Pain
 Differential diagnosis
Ureteric colic Appendicitis
Agonising pain passing from Migratory pain from epigastric
Pain
loin to the groin to the right lower abdomen

Fever Absent Present

Position Move around Lie still in bed
Tenderness and referred
Abdomen Flat and soft
tenderness
Urine Hematuria Normal
blood Normal Abnormal
Ultrasonography Stones Abdominalmass
7. Investigation of
suspected urinary stone disease
 Ultrasonography
 KUB films
 Intravenous Urography 尿路造影术 (IVU)
 Computed tomography (CT)
 Others
 1) Ultrasound scanning

 It may serve as first line screening for initial diagnosis.

 Renal and ureteral calculi and the consequence of obstruction
may be detected by ultrasonography.
 It is special valuable for radiolucent 射线透明的 calculi.
 2) CT

– Noncontrast spiral CT scans are now the imaging modality of choice in

emergent situations
– Do not need bowel preparation
– the imagines do not give anatomic details as seen on an IVU that may be
important in planning intervention.
 3) KUB + IVU

 Need adequate bowel preparation

 Can document simultaneously nephrolithiasis and upper-tract anatomy
 A delayed, planned IVU is necessary to verify stones location and also
affords a qualitative measure of renal function.
 A nonopaque 透 X 线的 stone (uric acid) will be seen as a radiolucent
defect in the opaque 不透明 contrast media.
4) Others
 Retrograde urography 尿路造影术

– Retrograde urography occasionally is required to delineate

upper-tract anatomy and localize small or radiolucent offending
calculi
 MRI
– It is a poor study to document urinary stone disease
 Nuclear scintigraphy 闪烁扫描法

– Cannot delineate 描述 upper-tract anatomy in sufficient detail to

help direct a therapeutic plan
– Occasionally useful in planning a nephrectomy 肾切除术
8. Treatment

 Pain
 Non-steroidal anti-inflammatory drugs (NSAID)
 Preoperative treatment
 Appropriate antibiotic
 Surgical treatment of urinary calculi
Surgical treatment of urinary calculi

– Conservative management
– Minimal invasive stone remove
– Open surgical removal of stones

Depends on stone size, shape, location, renal function,

and the associated situations
 1) Conservative management
 Conservative observation
 for small non-obstructive, asymptomatic caliceal （盏） stones
 Hydration and dietary management
 may be sufficient to prevent growth of existing or new
calcium stones in patients without metabolic abnormalities.
 Relief of obstruction
 Non-steroidal anti-inflammatory drugs and smooth muscle
relaxants
 Retrograde placement of a double-J ureteral stent

 Percutaneous nephrostomy tube

 Conservative observation

Combined data from two studies provide an estimate of percentages of stones

first seen in the pelvic ureter and their likelihood of retention for 1 year.
Relief of obstruction
Obstructive urinary calculi presents with
 severe pyelonephritis （肾盂肾炎）
 single kidney
 bilateral ureteral stones

requires emergent drainage

 Retrograde placement of ureteral stent
 Place a percutaneous nephrostomy tube
2) Minimal invasive stone remove
 ≥95% of urinary calculi can be removed
by minimal invasive techniques

– Extracorporeal shock-wave lithotripsy (ESWL)

– Percutaneous nephrolithotomy (PCNL)
– Ureteroscopic lithotomy
 1st Extracorporeal shock-wave
lithotripsy (ESWL) 震波碎石

 ESWL uses sound waves to break a kidney stone into

fragments that most pass do so within a 2-week period
 Indications:
– renal stones smaller than 2 cm
– proximal and distal ureteric stones
 Contraindications:
– Acute urinary tract infection
– uncorrected bleeding disorders
– pregnancy with distal ureteric stones
– sepsis
– uncorrected obstruction distal to the stone

Schematic view of an
电路原理图

electromagnetic shock-wave generator

an electromagnetic shock-wave generator that uses a parabolic

reflector to focus the shock wave. An electromagnetic coil is
used to generate the shock wave.

Complications of ESWL
Complications Managements
Pain Non-steroidal anti-
inflammatory drug
Stone Street Double J stent
Ureteroscopic lithotomy
Infection Prophylactic antibiotics
2nd Ureteroscopic lithotomy 切石术
3rd Percutaneous nephrolithotomy (PCNL)
Percutaneous removal of renal or proximal ureteral
calculi is the treatment of choice for
 large (> 2.5 cm) calculi,
 those resistant to ESWL,

 instances with evidence of obstruction

3) Open surgical removal of stones

 Endoscopic intervention and ESWL have markedly

decreased the indications for open surgery.
 Rarely, both percutaneous nephrolithotomy and
ESWL will be contraindicated, and open
nephrolithotomy will be necessary.
9. Prevention of recurrence
 Drink plenty to keep urine >2000ml/day
 This measure alone may decrease stone-forming potential by
50%
 Dietary advice is useful in:
 Hyperurincaemia 尿酸血症
 Cystinuria 胱氨酸血症
 Hyperparathyroidism must be treated
Topic 2nd

I. Urinary stone disease

II. Renal trauma
III. Urethral trauma
Etiology
 Blunt (80%)
-pedestrian struck, motor vehicle crash (MVC), sports, fall
 Penetrating
-gunshot wounds, stab wounds)
 Iatrogenic ( 医源性的 )
-endourologic 腔道泌尿外科 procedures, extracorporeal shock-wave
lithotripsy 震波碎石 , renal biopsy, percutaneous renal procedures
Clinical features of closed renal trauma
 Local pain and tenderness
 Haematuria
 Severe delayed haematuria
 Abdominal distension
 Radiographic or surgical exploration
Imaging Studies

 Ultrasonography
 Computed tomopraphy
(CT)
 Excretory urography (IVU)
 Angiography
Contrast-enhanced CT
 Computed tomographic
scan of a right renal stab
wound (grade IV),
demonstrating extensive
urinary extravasation 溢出物
and large retroperitoneal
hematoma.
Excretory urography (IVU)
 Excretory urography
demonstrating extravasation
in the upper right ureter
consequent to stab wound.
 Note lack of contrast (arrow)
in the ureter below the site of
injury, indicating complete
ureteral transection.
Pathology & classification
Pathology & classification
Grade Type Description
Contusion Microscopic or gross hematuria, urologic studies normal
I
Hematoma Subcapsular, nonexpanding without parenchymal laceration
Nonexpanding perirenal hematoma confined to renal
Hematoma
retroperitoneum
II
<1cm parenchymal depth of renal cortex without urinary
Laceration
extravasation
>1cm parenchymal depth of renal cortex without collecting system
III Laceration
rupture or urinary extravasation
Parenchymal laceration extending through renal cortex, medulla,
Laceration
IV and collecting system
Vascular Main renal artery or vein injury with contained hemorrhage
Laceration Completely shattered kidney
V Avulsion of the main renal artery and/or vein
Vascular
Thrombosis of the main renal artery
Treatment
 98% of renal injuries can be managed nonoperatively.
 Grade IV and V injuries more often require surgical
exploration
Conservative treatment
 Complete resuscitation
 Treatment of hemorrhage
 The patient must be confined to bed
 Antibiotics
Surgical Therapy
 The goals of operative therapy
– hemorrhage control
– renal tissue preservation
Indications for renal exploration
 Absolute indications
– Hemodynamic instability
– Expanding hematomas or active hemorrhage
– Unrelenting gross hematuria
Indications for renal exploration
 Relative indications
– nonviable tissue and major laceration
– urinary extravasation
– vascular injury
– incomplete staging
– laparotomy for associated injury
Outcome

 follow up with IVP or CT before discharge, and

at 6 weeks
 hypertension in 5% of renal trauma
Topic 3th

I. Urinary stone disease

II. Renal trauma
III. Urethral trauma
Etiology
 Most common site is membranous or bulbar
urethra due to blunt trauma
 Other causes:
– Iatrogenic 医源性 instrumentation,
– prosthesis 假体 insertion,
– penile fracture.
Rupture of the bulbar urethra

projecting object

extravasation

 Left: a perineal blow or fall astride an projecting object; crushing of

urethra against inferior edge of pubic symphysis.
 Right: extravasation of blood and urine enclosed within colles’ fascia
Rupture of the membranous urethra
 Injury to the
menbranous urethra is
usually a consequence
of pelvic fracture:
– A, normal anatomy;
– B, rupture below
the prostatic apex;
– C, rupture at the
membranous/bulbar
urethral junction.
Clinical features
 The signs of a ruptured bulbar urethra are
 retention of urine;
 perineal hematoma;
 bleeding from the external urinary meatus ( 尿道外
口 ).
Clinical features
 Rupture of the menbranous urethra is usually
a consequence of pelvic fracture. The patient
may present
 multiple trauma;
 urine retention;
 extravasation.
Diagnosis
 History of accident
 Signs and symptoms
 high riding prostate
 blood at urethral meatus

 sensation of voiding without urine output

 swelling and butterfly perineal hematoma

 Plain radiograph
 Ascending or retrograde urethrogram
 demonstrates extravasation and location of injury
 Flexible cystoscopy
Plain radiograph
A major urethral
disruption is almost
certain if there is
significant displacement
of the pubic bones
Ascending and/or Retrograde urethrogram
 Complete posterior
urethral disruption

 Extravasation of
urine
Extravasation of urine

Superficial extravasation Deep extravasation

(bulbar urethra trauma) (menbranous urethra trauma)
Initial treatment
 No voiding and urethral catheterization should be
allowed until assessment of the urethra is complete.
 Superpubic percutaneous and catheterization if the
bladder is full.
 Then imagine study.
 Further treatment
 Urethral contusion 挫伤 or partial tear
– No catheter is needed
– A course of prophylactic antibiotics
 Urethral lacerations 撕裂

– Superpubic percutaneous and catheterization

 Voiding study 2-3 weeks later
 Remain until repair
– Extensive urinary extravasation must be drainaged
– Intraperitoneal bladder injury demands exploration and repair
– Strictures require delayed reconstruction
Complications
 Extravasation
 Strictures
 Infection
 Impotence 阳痿
 Rupture of the Rupture of the
bulbar urethra membranous urethra
Injury type Blunt perineal trauma Pelvic fracture

Clinical Inability to urinate Inability to urinate

features Bleeding or hematuria Shock
Hematoma Multiple trauma
Investigation Ascending urethrogram Plain radiograph
Retrograde cystogram

Treatment Urethral catheterization Resuscitation

or suprapubic cystostomy Suprapubic cystostomy
Delayed repair Delayed repair
Urethoscope endourethrotomy

complications Extravasation of urine Extravasation of urine

Stricture Stricture
Urinary incontinence
Impotence