Transcript ECTOPIC KIDNEY - 上海交通大学医学院精品课程

ECTOPIC KIDNEY
Ectopic kidney usually causes no symptoms unless
complications such as ureteral obstruction or
infection develop
Congenital disorders. Is a low kidney on the proper
side which failed to ascend normally. (Over the
pelvic brim. In the pelvis).
Prone to ureteral obstruction and infection, which
may lead to pain or fever.
 Palpable
examination may find such a kidney,
leading to an erroneous presumptive diagnosis, eg,
cancer of the bowel, appendiceal abscess.
 Excretory or retrograde urograms will reveal the
true position. Hydronephrosis, if present, will be
evident. There is no redundancy of the ureter, as is
the cause with nephroptosis or acquired ectopy(eg,
displacement by large suprarenal tumor.
 Obstruction
and infection may complicate ectopy
and should be treated by appropriate means.
 Anatomic vision: normal pelvic at the position of
No. 1 or 2 lumbar vertebral level, kidney mobility
range is 1—4 cm with respiration . Kidney
descending level is much than this range at the
position of standing we call Ectopic Kidney.
VARICOCELE
 Varicocele
is common in young men and consists
of dilatation of the pampiniform plexus above the
testis. The left side is most commonly affected.
 These veins drain into the internal spermatic vein
in the region of the internal inguinal ring. This vein
passes lateral to the vas deferens at the internal
inguinal ring and, on the left side, drain into the
renal vein. On the right it empties into vena cava.
 The
left internal spermatic vein is particularly
liable to have incompetent valves. This fact, plus
gravity, may lead to poor drainage of the
pampiniform plexus, the veins of which gradually
undergo dilatation and elongation. At times they
are painful.
 Sudden development in an old men is sometimes
as a late sign of renal tumor which invaded renal
vein, thereby occluding the spermatic vein.
 Examination
upright reveals a mass of dilated,
tortuous vein lying posterior to and above the testis.
 The degree of dilatation can be increased by the
Valsalva maneuver. In the recumbent position,
venous distention abates. Testicular atrophy from
impaired circulation may be present.
 No treatment is required unless the varicocele is
thought to contribute to infertility or is painful or
so large as to disturb the patient.
Treatment: scrotal support will relieve discomfort;
ligation of internal spermatic vein (at the internal
inguinal ring or HIGH ligation) is indicated. The
results from this operation are excellent,
particularly in the treatment of infertility. Vein
atomosis also applied in clinic and micro injure
operation by larparoscopy is more fasionable.
HYDROCELE
 A hydrocele
consists of a collection of fluid within
tunica or processus vaginalis. It may occur within
the spermatic cord.
 Hydrocele of tunica vaginalis is common in the
newborn, as a result of late closure of the
processus vaginalis, which is continuous with the
peritoneum. Most of these fluid collection subside
spontaneously during the first few weeks of life.
 Causes:
secondary to local injury; acute
nonspecific or tuberculous epididymitis, or orchitis.
 Clinical findings:
Young boys with hydrocele commonly have a
history of a cystic mass which is small and soft in
the morning but large and more tense at night. One
can only conclude, in these instances, that a small
communication exists in the processus vaginalis
between the peritoneal cavity and the tunica
vaginalis. Hernia or communicating hydrocele is
therefore the proper diagnosis.
Hydrocele is painless unless it is accompanied by
acute epididymal infection. Patient may complain
of its bulk or weight.
 Diagnosis
made by finding a rounded cystic
intrascrotal mass which is not tender unless
underlying inflammatory disease is present.
 Mass is transilluminate
 If hydrocele is enclosed within the spermatic cord,
a cystic fusiform swelling is noted in the groin or
in the upper scrotum.
 Differentiated
diagnosis: a tense hydrocele which
dose not transilluminate must from tumor of the
testis or tuberculosis.
 Complications include compression of the blood
supply of the testicle, which lead to atrophy;
hemorrhage into the hydrocele sac following
trauma or aspiration(hematocele); or, rarely,
infection complicating aspiration.
 Treatment
unless complication are present, active
therapy is not required. The indications for
treatment are a very tense hydrocele which might
embarrass circulation to the testicle or a large, bulk
mass which is cosmetically unsightly and perhaps
uncomfortable for the patient.
 One aspiration of a dydrocele that is present during
the first few months of life is often curative
the parietal tunica vaginalis should be resected for
chronic hydrocele which refill slowly, after
repeated aspiration. Secondary infection may
required incision and drainage. Hematocele should
be treated by resection of the hydrocele sac.
RENOVASCULAR
HYPERTENSION
 Renal
ischemia could produce hypertension.
 Etiology and Pathogenesis why the ischemic
kidney causes elevation of blood pressure, the
theory has been the following: decreased blood
flow through the afferent glomerular arteries leads
to an increased number of secretory granules in the
juxtaglomerular bodies, which are thought to
elaborate renin. This enzyme reacts with an alpha
globulin to produce angiotensin l, which acted
upon by a converting enzyme, it is changed to
angiotensin ll, a potent vasoconstrictor which
also acts to increase aldosterone secretion by the
adrenal cortex. Thus, hypertension is
established.
Sever Hypertension caused by stenosis of the renal
artery. Renin has been found increased amounts
from the renal vein of ischemic organ.
 The
common causes of renal artery are
arteriosclerotic plques, fibromuscular hyperplasia
of the media(which usually affects relatively
young females and children),
neurofibromatosis(most often seen in children),
and embolism or thrombosis, etc. chronic
pyelonephritis, aneurysm of the renal artery,
hydronephrosis, renal tumors, and renal
tuberculosis.
 Clinical
findings:
A. Symptoms: 1.family history of hypertension,
particularly young patients. 2.Sever flank pain or
abdominal pain or trauma with or without
hematuria(suggesting emblism or thrombosis of
renal artery or an organized perirenal hematoma).
3.If there is abrupt acceleration of preexisting
hypertension,esp. in an older person.
 Clinical
findings:
A. Symptoms: 4. In the presence of sever
hypertension in any age.
B. Signs: sustained diastolic hypertension; retinas
changes; renal mass may found eg, renal tumor;
the presence of an aortic aneurysm or vascular
insufficiency of the extremities is suggestive.
 Clinical
findings:
C. Lab. Findings:
Bacteria and pus cells in urine may indicate
chronic pyelonephritis. In the malignant phase of
hypertension, proteinuria, casts, and red cell will
be seen. Total renal function is usually normal
unless malignant hypertension, polycystic disease,
bilateral atrophic pyelonephritis, or bilateral renal
artery stenosisis present.
 Clinical
findings:
D. X-ray findings: excretory urography is
screening test: Delay in appearance of the
radiopaque medium is a importance sign. The
following findings are suggestive of renal ischemic:
1. A kidney at least 1 cm shorter than its mate; 2.
Lack of function of one kidney; 3. Delayed
appearance of visualization on the early films; 4.
Hyperconcentration of the radiopaque medium due
to overabsorption of water.
the urographic changes of chronic pyelonephritis,
hydronephrosis, and polycystic disease should be
obvious.
E. renal isotope study: renogram and scan show
slow excret of isotope.
F. Estimation of renal vein renin level: its great
value in establishing the diagnosis of renovascular
hypertension.
G. Renal angiography: showing significantly
stenotic lesion of renal artery.
H. A positive saralasin test is strong evidence.
 Treatment
surgery should be done in order to protect renal
function from effects of high blood perssure.
Nephrectomy. ( poor renal function)
Endarterectomy, homograft, sleeve resection of
involved arterial segment. ( good renal function)
Vaso-Catheter dilatation.( micro-invade)
Renal arterial reconstruction operation. (riskness)
 Treatment
preoperation preparation:
Control blood pressure by a-block and b-block
drugs.