surgical anatomy surgery of the kidney - kisallatsebeszet.hu · surgery of the kidney dr. t....

Surgery of the KidneySurgery of the KidneySurgery of the KidneySurgery of the Kidney

Dr. T. Németh, DVM, Ph.DDr. T. Németh, DVM, Ph.DDr. T. Németh, DVM, Ph.DDr. T. Németh, DVM, Ph.D

Surgical anatomySurgical anatomySurgical anatomySurgical anatomy

Surgical Diseases of the Surgical Diseases of the KidneyKidney


HydronephrosisHydronephrosis

NephrolithiasisNephrolithiasis

Renal neoplasiaRenal neoplasia

Renal injuriesRenal injuries















HydronephrosisHydronephrosisHydronephrosisHydronephrosis

Forms:– congenital (unilateral - bilateral)– acquired (unilateral - bilateral)

Etiology ureter-occlusion ! (ureter-stricture, -compression, - calculus, -neoplasia, -stenosis)

Forms:– congenital (unilateral - bilateral)– acquired (unilateral - bilateral)

Etiology ureter-occlusion ! (ureter-stricture, -compression, - calculus, -neoplasia, -stenosis)

UreterUreter--occlusionocclusion(experimental)(experimental)

UreterUreter--occlusionocclusion(experimental)(experimental)

Total obstruction– Intra-ureteral pressure increases within the first 5 hours

then decreases until12 to 24 hours– Blood perfusion of the kidney drops to 40% for the first

24 hours then to 20% until the end of 2nd week– GFR falls too

Post-obstruction regeneration– After 1-week ureter obstruction GFR returns to 65% then

to 100% within 5 weeks– After 2-week ureter occlusion GFR returns to 46% within

4 months

Total obstruction– Intra-ureteral pressure increases within the first 5 hours

then decreases until12 to 24 hours– Blood perfusion of the kidney drops to 40% for the first

24 hours then to 20% until the end of 2nd week– GFR falls too

Post-obstruction regeneration– After 1-week ureter obstruction GFR returns to 65% then

to 100% within 5 weeks– After 2-week ureter occlusion GFR returns to 46% within

4 months


Diagnosis:– generally asymptomatic (unilateral)– physical findings: abdominal palpation (rare)– laboratory: uraemia (bilateral)– US (!)– X-ray: plain, excretory urography

Therapy: nephrectomy

Diagnosis:– generally asymptomatic (unilateral)– physical findings: abdominal palpation (rare)– laboratory: uraemia (bilateral)– US (!)– X-ray: plain, excretory urography


HydronephrosisHydronephrosisUltrasonographyUltrasonography

HydronephrosisHydronephrosisUltrasonographyUltrasonography


Diagnostics:– generally asymptomatic (unilateral)– physical findings: abdominal palpation (rare)– laboratory: uremia (bilateral)– US (!)– X-ray: plain (excretory urography)




HydronephrosisHydronephrosisExcretory urographyExcretory urographyHydronephrosisHydronephrosisExcretory urographyExcretory urography






HydronephrosisHydronephrosisNephrectomyNephrectomy






NephrectomyNephrectomyNephrectomyNephrectomy HydronephrosisHydronephrosisNephrectomyNephrectomy














NephrolithiasisNephrolithiasisNephrolithiasisNephrolithiasis IncidenceIncidence, Aetiology, Aetiology

–– uncommonuncommon–– breedbreed--predispositionpredisposition ((e.ge.g. dalmatian, bishon). dalmatian, bishon)

–– alimentaryalimentary backgroundbackground ((e.ge.g. protein . protein overfeedingoverfeeding))

–– pyelonephritispyelonephritis–– portovascularportovascular anomalyanomaly ((ammoniumammonium urateurate !)!)

–– hypercalcemia hypercalcemia (malignancies)(malignancies)

–– struvitestruvite (Mg(NH(Mg(NH44)PO)PO44), urate (Dalmatian) ), urate (Dalmatian) CaCa--phosphate, Caphosphate, Ca--oxalate (bishon), oxalate (bishon), silicatesilicate

IncidenceIncidence, Aetiology, Aetiology–– uncommonuncommon–– breedbreed--predispositionpredisposition ((e.ge.g. dalmatian, bishon). dalmatian, bishon)

–– alimentaryalimentary backgroundbackground ((e.ge.g. protein . protein overfeedingoverfeeding))

–– pyelonephritispyelonephritis–– portovascularportovascular anomalyanomaly ((ammoniumammonium urateurate !)!)

–– hypercalcemia hypercalcemia (malignancies)(malignancies)

–– struvitestruvite (Mg(NH(Mg(NH44)PO)PO44), urate (Dalmatian) ), urate (Dalmatian) CaCa--phosphate, Caphosphate, Ca--oxalate (bishon), oxalate (bishon), silicatesilicate

NephrolithiasisNephrolithiasisNephrolithiasisNephrolithiasis

DiagnosticsDiagnostics–– unilaterallyunilaterally asymptomaticasymptomatic–– anorexia, lethargyanorexia, lethargy–– „irresponsive„irresponsive” ” hematuriahematuria, , proteinuriaproteinuria–– crystalscrystals inin thethe sedimentsediment–– bilaterallybilaterally: : uremiauremia–– XX--rayray ((plainplain, , contrastcontrast))–– USUS

DiagnosticsDiagnostics–– unilaterallyunilaterally asymptomaticasymptomatic–– anorexia, lethargyanorexia, lethargy–– „irresponsive„irresponsive” ” hematuriahematuria, , proteinuriaproteinuria–– crystalscrystals inin thethe sedimentsediment–– bilaterallybilaterally: : uremiauremia–– XX--rayray ((plainplain, , contrastcontrast))–– USUS

NephrolithiasisNephrolithiasisPlain radiographyPlain radiography

NephrolithiasisNephrolithiasisPlain radiographyPlain radiography

NephrolithiasisNephrolithiasisExcretory urographyExcretory urographyNephrolithiasisNephrolithiasisExcretory urographyExcretory urography

NephrolithiasisNephrolithiasisNephrolithiasisNephrolithiasis

DiagnosticsDiagnostics–– unilaterallyunilaterally asymptomaticasymptomatic–– „„irresponsiveirresponsive” ” hematuriahematuria, , proteinuriaproteinuria–– crystalscrystals inin thethe sedimentsediment–– bilaterallybilaterally: : uremiauremia–– XX--rayray ((plainplain, , contrastcontrast))–– USUS

DiagnosticsDiagnostics–– unilaterallyunilaterally asymptomaticasymptomatic–– „„irresponsiveirresponsive” ” hematuriahematuria, , proteinuriaproteinuria–– crystalscrystals inin thethe sedimentsediment–– bilaterallybilaterally: : uremiauremia–– XX--rayray ((plainplain, , contrastcontrast))–– USUS

NephrolithiasisNephrolithiasisUltrasonographyUltrasonography

NephrolithiasisNephrolithiasisUltrasonographyUltrasonography

NephrolithiasisNephrolithiasisNephrolithiasisNephrolithiasisTherapyTherapy

MedicalMedical–– dissolutiondissolution dietdiet++drugdrug ((struvitstruvit, , urateurate, , cystinecystine))–– lithotripsylithotripsy (extra(extra-- oror intracorporealintracorporeal))

SurgicalSurgical–– pyelotomypyelotomy–– nephrotomynephrotomy–– nephrectomynephrectomy

TherapyTherapyMedicalMedical

–– dissolutiondissolution dietdiet++drugdrug ((struvitstruvit, , urateurate, , cystinecystine))–– lithotripsylithotripsy (extra(extra-- oror intracorporealintracorporeal))


NephrolithiasisNephrolithiasisPyelotomyPyelotomy

NephrolithiasisNephrolithiasisPyelotomyPyelotomy







NephrolithiasisNephrolithiasisNephrotomyNephrotomy






NephrectomyNephrectomyNephrectomyNephrectomy NephrolithiasisNephrolithiasisNephrectomyNephrectomy

NephrolithiasisNephrolithiasisNephrectomyNephrectomy













Renal neoplasiaRenal neoplasiaRenal neoplasiaRenal neoplasia

Incidence:– in dogs: 1,7-2% of tumours

– in cats: 2,5% of tumours

– benign (adenoma, interstitial tumor)

– malignant (tubular cell carcinoma; cystadenocarcinoma, TCC, SCC, HSA, LSA/cat, FSA, congenital nephroblastoma)

– metastasis (LSA/cat!, liver, biliary tract)

Incidence:– in dogs: 1,7-2% of tumours

– in cats: 2,5% of tumours

– benign (adenoma, interstitial tumor)

– malignant (tubular cell carcinoma; cystadenocarcinoma, TCC, SCC, HSA, LSA/cat, FSA, congenital nephroblastoma)

– metastasis (LSA/cat!, liver, biliary tract)

Renal neoplasiaRenal neoplasiaRenal neoplasiaRenal neoplasiaDiagnosis: non specific signs

– anorexia, weight loss– polycytemia (in cat)– polyuria, polydypsia, haematuria, tumour cells in

urine sediment , uremia– US (FNA, biopsy) – X-ray (excretory urography)

Therapy:– Surgical:nephrectomy (partial;total)– Chemotherapy + Local radiotherapy

Diagnosis: non specific signs– anorexia, weight loss– polycytemia (in cat)– polyuria, polydypsia, haematuria, tumour cells in



Renal neoplasiaRenal neoplasiaUS guided kidney biopsyUS guided kidney biopsy

Renal neoplasiaRenal neoplasiaUS guided kidney biopsyUS guided kidney biopsy








Renal neoplasiaRenal neoplasiaRenal carcinoma Renal carcinoma -- Plain radiographyPlain radiography





Therapy:– Surgical:nephrectomy (partial; total)– Chemotherapy + Local radiotherapy




Renal neoplasiaRenal neoplasiaPartial nephrectomyPartial nephrectomyRenal neoplasiaRenal neoplasiaPartial nephrectomyPartial nephrectomy Renal neoplasiaRenal neoplasiaRenal neoplasiaRenal neoplasia











Renal neoplasia Renal neoplasia Metastatic renal tumour Metastatic renal tumour

(from liver biliary carcinoma(from liver biliary carcinoma))

Renal neoplasia Renal neoplasia Metastatic renal tumour Metastatic renal tumour

(from liver biliary carcinoma(from liver biliary carcinoma))




Therapy:– Surgical:nephrectomy (partial; total)– Chemotherapy + Local radiotherapy???



Therapy:– Surgical:nephrectomy (partial; total)– Chemotherapy + Local radiotherapy???











Renal injuriesRenal injuriesRenal injuriesRenal injuries

Incidence:–blunt trauma (contusion; hematoma,

rupture, laceration, avulsion)

– sharp trauma (stab, shot injury)

Incidence:–blunt trauma (contusion; hematoma,

rupture, laceration, avulsion)

– sharp trauma (stab, shot injury)


Diagnostics: – trauma in history– haematuria– blood in the peritoneal fluid or in the

retroperitoneum– X-ray (excretory urography) – US– exploratory laparatomy

Diagnostics: – trauma in history– haematuria– blood in the peritoneal fluid or in the

retroperitoneum– X-ray (excretory urography) – US– exploratory laparatomy

Renal injuries Renal injuries retroperitoneal hematomaretroperitoneal hematoma




Renal injuriesRenal injuriesShot injuryShot injury



Therapy:–suturing (supf. rupture)–hematoma-drainage?–nephrectomy (partial; total)


Partial nephrectomyPartial nephrectomyPartial nephrectomyPartial nephrectomy




Renal injuriesRenal injuriesRupture of the kidneyRupture of the kidneyRenal injuriesRenal injuries

Rupture of the kidneyRupture of the kidney



Surgery of the UreterSurgery of the UreterSurgery of the UreterSurgery of the Ureter

Surgical anatomySurgical anatomySurgical anatomySurgical anatomySurgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the Ureter

Hydroureter (hydronephros)Hydroureter (hydronephros)

Ectopic ureterEctopic ureter

UreterUreter--calculuscalculus

UreterUreter--injuriesinjuries





Surgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the Ureter









Ectopic ureterEctopic ureterEctopic ureterEctopic ureter

Incidence: abnormal opening of the ureter(urethra, vagina)

– uni- or bilateral

– extra- (cats) or intramural (dogs)– associated with other disorders

(renal hypoplasia, ureterocele, ureter-dilatation, hydronephrosis etc.)

– breed predisposition (labrador, golden, husky, west highland white terrier, foxterrier, sky terrier, poodle)

Incidence: abnormal opening of the ureter(urethra, vagina)

– uni- or bilateral

– extra- (cats) or intramural (dogs)– associated with other disorders

(renal hypoplasia, ureterocele, ureter-dilatation, hydronephrosis etc.)

– breed predisposition (labrador, golden, husky, west highland white terrier, foxterrier, sky terrier, poodle)

Ectopic ureterEctopic ureterEctopic ureterEctopic ureterDiagnosis:

– urinary incontinence unilateral ectopia: normal urination and incontinence bilateral ectopia: complete and constant incontinence (sometimes signs of urina in males, rarely in females)

– urinary infection– X-ray: excretory urography + pneumo-

cystography; vaginography– Cystoscopy

Types: – Intramural or extramural

Diagnosis:– urinary incontinence

unilateral ectopia: normal urination and incontinence bilateral ectopia: complete and constant incontinence (sometimes signs of urina in males, rarely in females)

– urinary infection– X-ray: excretory urography + pneumo-



Ectopic ureterEctopic ureterExcretory urographyExcretory urographyEctopic ureterEctopic ureter

Excretory urographyExcretory urography

Ectopic ureterEctopic ureterEctopic ureterEctopic ureterDiagnostics:


– signs of urinary infection– X-ray: excretory urography + pneumo-

cystography; vaginography– cystoscopy


Diagnostics:– urinary incontinence



cystography; vaginography– cystoscopy


Ectopic ureterEctopic ureterPositive contrast vaginographyPositive contrast vaginography

Ectopic ureterEctopic ureterPositive contrast vaginographyPositive contrast vaginography

Ectopic ureterEctopic ureterEctopic ureterEctopic ureterDiagnostics:





Diagnostics:– urinary incontinence





EctopicEctopic ureterureterCystoscopyCystoscopy

EctopicEctopic ureterureterCystoscopyCystoscopy

UreterUreter--orificeorifice

urethraurethra

Intramural Intramural

Ectopic ureterEctopic ureterEctopic ureterEctopic ureter

Urinary bladder

Ectopic ureter

ExtramuralExtramuralEctopicEctopic ureterureterEctopicEctopic ureterureter

Therapy:– trigone reconstruction (intramural)– „ureteroneocystostomy” (extramural)

– nephro-ureterectomy (hydroureter-hydronephrosis)



Ectopic ureterEctopic ureterTTrigonerigone--rekonstructionrekonstruction

Ectopic ureterEctopic ureterTTrigonerigone--rekonstructionrekonstruction

EctopicEctopic ureterureterTrigone reconstruction (intramural)

EctopicEctopic ureterureterTrigone reconstruction (intramural)

EctopicEctopic ureterureterEctopicEctopic ureterureter





Ectopic ureterEctopic ureterUreteroneocystostomyUreteroneocystostomy




ureter

ureter



ureterUrinary bladder



ureter

Urinary bladder



ureter

Urinary bladder

EctopicEctopic ureterureterEctopicEctopic ureterureter





Ectopic ureterEctopic ureterExcretory urographyExcretory urographyEctopic ureterEctopic ureter

Excretory urographyExcretory urography

Ectopic ureterEctopic ureterNephroNephro--ureterectomyureterectomyEctopic ureterEctopic ureter

NephroNephro--ureterectomyureterectomyEctopic ureterEctopic ureter

NephroNephro--ureterectomyureterectomyEctopic ureterEctopic ureter

NephroNephro--ureterectomyureterectomy

Surgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the Ureter









UreterUreter--calculuscalculusUreterUreter--calculuscalculus associated with nephrolythiasis (50% coincidence)

Diagnostics:– In dogs and cats– Struvite, oxalate– in unilateral cases: asymptomatic– abdominal pain– X-ray / excretory urography– US– consecutive hydroureter/hydronephros

associated with nephrolythiasis (50% coincidence)

Diagnostics:– In dogs and cats– Struvite, oxalate– in unilateral cases: asymptomatic– abdominal pain– X-ray / excretory urography– US– consecutive hydroureter/hydronephros

UreterUreter--calculuscalculusExcretory urographyExcretory urographyUreterUreter--calculuscalculusExcretory urographyExcretory urography


UreterUreter--calculuscalculusUreterUreter--calculuscalculus

Therapy:–ureterotomy–ureter-resection / anastomosis–nephro-ureterectomy


UreterUreter--calculuscalculusUreterotomy Ureterotomy -- Ureter calculusUreter calculus






Ureter calculusUreter calculusUreterUreter--stenting („pigtail” stenting („pigtail” catheter)catheter)

Ureter calculusUreter calculusUreterUreter--stenting („pigtail” stenting („pigtail” catheter)catheter) UreterUreter--calculuscalculusUreterUreter--calculuscalculus



UreterUreter--anastomosisanastomosisUreterUreter--anastomosisanastomosis UreterUreter--calculuscalculusUreterUreter--calculuscalculus





UreterUreter--calculuscalculusNephroNephro--ureterectomyureterectomyUreterUreter--calculuscalculus

NephroNephro--ureterectomyureterectomyUreterUreter--calculuscalculus

NephroNephro--ureterectomyureterectomyUreterUreter--calculuscalculus

NephroNephro--ureterectomyureterectomy

UreterUreter--calculuscalculusNephroNephro--ureterectomyureterectomyUreterUreter--calculuscalculus

NephroNephro--ureterectomyureterectomy Surgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the UreterSurgical Diseases of the Ureter









UreterUreter--injuriesinjuriesUreterUreter--injuriesinjuries

Incidence/Aetiology– rare– iatrogenic (OE/OHE)– blunt abdominal trauma

Incidence/Aetiology– rare– iatrogenic (OE/OHE)– blunt abdominal trauma

UreterUreter--injuriesinjuriesUreterUreter--injuriesinjuries

Diagnosis:– unilateral or bilateral

– signs may develop days after injury– abdominal pain – uremia

– uroperitoneum (diagnostic puncture: Creat, K+ )

– uroretroperitoneum– X-ray: excretory urography (contrast spot)

– US (free fluid)

Diagnosis:– unilateral or bilateral

– signs may develop days after injury– abdominal pain – uremia

– uroperitoneum (diagnostic puncture: Creat, K+ )

– uroretroperitoneum– X-ray: excretory urography (contrast spot)

– US (free fluid)

UreterUreter--injuriesinjuriesTorn uretersTorn ureters





UreterUreter--injuriesinjuriesTorn uretersTorn ureters UreterUreter--injuriesinjuriesUreterUreter--injuriesinjuries

Therapy:–ureter resection / anastomosis

–ureteroneocystostomy

–nephro-ureterectomy




UreterUreter--injuriesinjuriesUreterUreter--anastomosisanastomosisUreterUreter--injuriesinjuries

UreterUreter--anastomosisanastomosis UreterUreter--injuriesinjuriesUreterUreter--injuriesinjuries







surgical anatomy surgery of the kidney - kisallatsebeszet.hu · surgery of the kidney dr. t....

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