Urology Board Review

November 16, 2010

Hydronephrosis Hydroureteronephrosis Pyelectasis Pyelocaliectasis

Screening of fetus Need postnatal U/S

◦ If not urgent 3-10 days Allow increased urine production to fill

out defects◦ 20% resolution

f/u ultrasounds at several months and 1 year

Urinary Tract Dilation

On discharge examination of a female newborn infant, you notice a palpable mass in the right abdomen. An abdominal ultrasound reveals hydronephrosis. What is the next study that should be performed?

A. IVPB. CystoscopyC. VCUGD. Renal ScanE. No intervention at this time

Question 1

Postnatal hydronephrosis◦ Complete radiographic eval

VCUG** Rule out infravesical obstruction VUR

Other IV urography

True obstruction Radionuclide scan

Function Delay 4-6 weeks

Urinary Tract Dilation

Males Common cause of

infravesical obstruction

Associated with◦ Prenatal hydronephrosis◦ UTI◦ Incontinence◦ Renal Failure◦ Diminished urinary

stream

Posterior Urethral Valves

Neonates◦ Pulmonary hypoplasia◦ Renal failure◦ Bladder distention◦ Hydroureteronephrosis

Older children◦ Incontinence◦ Renal failure

Posterior Urethral Valves

Diagnosis◦ VCUG

Treatment◦ Endoscopic fulguration◦ Cutaneous vesicostomy

Smaller babies Prognosis

◦ Renal dysplasia◦ Bladder compliance

Worse prognosis if poorly compliant Reflux and hydronephrosis will not improve

Posterior Urethral Valves

33% preemies 3% Full term Associated abnormalities

◦ Renal ultrasound Urinary tract abnormalities are rare

◦ Hypospadias w/ unilateral cyptorchidism Intersex anomalies - karyotype

◦ Bilateral nonpalpable testes Endo eval

FSH, LH, testosterone

Treatment◦ Correction at 6-12 months

Could resolve on its own during this time◦ Cancer and Fertility risk

Cryptorchidism

AKA Eagle-Barrett Triad Boys 1/35,000-50,000

Triad◦ Abnormal abdominal musculature◦ Abdominal cryptorchidism◦ Floppy dysmorphic urinary tracts

VUR

Prune-Belly Syndrome

Other findings◦ Megalourethra◦ Prostatic hypoplasia◦ Dimples on lateral knees◦ GI◦ Cardiac

Risks◦ UTI with sepsis

Careful catheterization Prognosis

◦ Renal dysplasia

Prune-Belly Syndrome

A mother brings her infant into the office because she has noticed a continual drainage from her umbilicus. You suspect a patent urachus. You explain to the mother that this results from an abnormal communication between . . .

A. The bladder and umbilicusB. A ureter and the umbilicusC. The small intestine and the umbilicusD. The renal pelvis and the umbilicusE. The colon and the umbilicus

Question 2

Bladder dome to umbilicus◦ Vestigial structure

Persistence◦ Patent urachus◦ Vesicourachal diverticulum◦ Urachal cyst◦ Urachal sinus

Dx◦ U/S◦ CT

Tx◦ Excision

Source of carcinoma in adults

Urachus

Patent◦ Communication remains◦ Umbilical drainage◦ Inflammation◦ Infection

Urachal cysts◦ Infection ◦ Adulthood

Suprapubic or infraumbilical pain, tenderness, palpable mass or abdominal wall inflammation

Urachal Abnormalities

UPJ Obstruction◦ Presentation

Antenatal hydronephrosis Neonatal flank mass UTI Recurrent abdominal pain Co-existing VUR

Hydronephrosis

UPJ Obstruction◦ Dx

U/S IVP Retrograde pyelography* VCUG

Coextisting VUR Renal scan

True obstruction

Hydronephrosis

Megaureter◦ Large ureter with or

without intrarenal hydronephrosis

◦ Causes VUR Ureterovesical

obstruction Local neurologic or

muscular abnormality Nonobstructive*

Hydronephrosis

Megaureter

◦ Discovery Antenatal U/S UTI

◦ Treatment Some resolve

spontaneously Obstructive

Excision and reimplantation

Hydronephrosis

After palpating a left sided mass at a well visit in a 2 month old, a renal ultrasound shows that your patient has a multicystic dysplastic kidney. A renal scan of this dysplastic kidney is most likely to show . . .

A. Full functionB. No function C. 50% functionD. 25% functionE. 75% function

Question 3

2nd most common cause of renal enlargement in neonates

Discovery◦ Antenatal U/S◦ Abdominal mass

Dx◦ U/S

Enlarged kidney with non-communicating cysts

◦ Renal scan Multicystic kidneys rarely function

Multicystic Renal Dysplasia

Treatment◦ VCUG

Contralateral VUR UPJ obstruction, PUV,

megaureter and duplication◦ Long term F/U

15% involute Prognosis

◦ Low risk HTN Infection Malignancy

Multicystic Renal Dysplasia

Usually benign Usually incidental finding Evaluation

◦ U/S◦ CT◦ Cyst aspiration if suspicious

DDx◦ Cystic Wilms tumor◦ Multilocular cystic dysplasia◦ Duplication anomaly with

hydronephrosis◦ Calyceal diverticulum◦ Adult polycystic disease

Simple Renal Cysts