Renal Transplant

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Renal Transplant
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Immunology

• ABO Match (minimum requirement)
• HLA matching (6 Antigen Ideal)

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Renal Transplant

• Cadaveric (2 year wait)
• Live Related/Unrelated (30 of Transplants)

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Recipient Candidate

• lt65 years of age
• Adequate Iliac Vasculature
• Demonstrate Compliance Medication
• Reasonable Bladder Function

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Organ Must Fit

• Age Appropriate
• Filtration Needs
• Anatomy (PCK)

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Polycystic Kidney Disease
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Preoperative Testing

• Cross Match
• UA
• PE (CHF/UTI/URI)
• Donor and Recipient

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Cadaveric

• Organ Donors in Living Brain Dead Individuals
  after Cold Perfusion
• Kidneys are Separated and placed in Ice
• Transported to Recipient Site
• Coordinated by Organ Procurement Teams

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Live Donors

• Must Be ABO Match
• Relatives Are More Likely To Have A Negative
  Cross Match
• Unrelated Donors must undergo Psych Testing
• Paying For Kidneys Is Illegal in USA
• Laparoscopic Surgery Decreases Morbidity

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Procedure

• Kidney Artery and Vein Are Attached to Iliac
  Vessels
• The Ureter is Attached to the Bladder

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Selection

• Based on a Reasonable Match
• Time on the List
• Not Socioeconomic Status
• Not Mental or Physical Disabilities
• A 6 Antigen Match takes preference over time on
  List
• Transplanted up to 48 Hours after Procurement

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Immunosupression

• Cyclosporine
• Imuran
• Prednisone

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Graft Survival

• Cadaveric 90 one year
• Live Related 95 one year

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Hematuria
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Hematuria

• Microscopic Hematuria
• Gross Hematuria

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Normal Urinalysis

• No WBC
• No RBC
• No Protein
• No Glucose

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Hematuria

• Significant if gt2-3RBC/HPF
• Contamination (Epithelial Cells, Squamous Cells,
  Bacteria)
• Dipstick False
• Menstrual Period
• Urethral Prolapse/Atrophic Vaginitis
• Phimosis/Balanitis

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Diagnosis

• BPH
• Bladder Stones
• Renal Stone Dz
• Cancer

• Congenital
• Medical Renal Dz
• Anatomic
• Trauma

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Evaluation

• Evaluate Kidneys, Ureters, Bladder, Prostate
  (men), Urethra
• IVP/CT Scan
• Urine Cytology
• Cystoscopy

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IVP

• Bladder Tumor Filling Defects

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CASE

• 65 y/o male complains of blood in his urine and
  an interrupted urinary stream.
• PMH and exam is notable only for an enlarged
  prostate
• Labs show TNTC RBCs in urine

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CASE

• 85 y/o female complains of blood in her urine
  without burning or fevers chills. She had XRT
  for cervical cancer 20 years ago.
• Exam is otherwise benign
• Urinalysis shows 20-25 rbc/hpf

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CASE

• 51 y/o with L flank pain for 2 weeks and
  microscopic hematuria.

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Non-contrast CT
?dilated ureter
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Non-contrast CT

• Diagnosis?

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Stone Emergencies

• High grade obstruction
• Infection (particularly with obstruction)
• Intractable pain

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Urologic Emergencies
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Penis

• Phimosis
• Paraphimosis
• Circumcision
• Priapism
• Trauma

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Phimosis

• Unable to retract foreskin
• Only occurs in uncircumcised patients
• Usually due to repeated infections lead to
  scarring of foreskin
• Inflammation is called balanoposthitis
• Adult patients commonly have underlying diabetes

Phimotic ring
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Paraphimosis

• Unable to REDUCE foreskin
• Occurs only in uncircumcised patients
• Patient has component of phimosis
• But fails to reduce foreskin timely
• The constriction behind the glans tightens as the
  glans swells and a vicious cycle begins

Phimotic ring
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Paraphimosis Treatment

• Grasp penis firmly
• Squeeze excess fluid from the tissue distal to
  the phimotic ring

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Paraphimosis Treatment

• Push with thumbs
• Pull with index finger

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Paraphimosis Treatment

• Plan elective circumcision

Uncircumcised 15 y/o
Phimotic Ring
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Priapism

• Persistent painful erection
• Caused by
• Self injection of prescribed medicine
• Illicit drug use
• Alpha blocking activity
• THC
• Leukemic infiltrates in the corpora cavernosum
• Sickle cell anemia
• The corpora spongiosum is NOT involved
• Treatment
• Inject into the corpora epinephrine

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Priapism

• 50 possibility of permanent erectile dysfunction
• Due to alteration of normal penile architecture,
  whether from stasis or from surgical therapy
  employed to prevent ischemia.

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Treatment Options

• Penile irrigation/aspiration
• Shunting procedures

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Interesting Cases

• 32 y/o male having sexual intercourse
• Felt and heard a snap
• Immediately loss erection
• Penis became swollen

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Interesting cases

• 35 y/o male weight lifter
• Looking for more weighty erection

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Interesting Cases

• 28 y/o mechanic
• Rebuilds engines
• Dissatisfied with sexual prowess
• Considers himself ingenuous and resourceful
• Comes in with an obvious complaint

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The Acute Scrotum

• Scrotal/Testicular pain has multiple causes, some
  of which are true emergencies.
• A careful history and physical exam can usually
  make the diagnosis.
• Scrotal US very helpful in confirming diagnosis.

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History

• Characterize the pain
• Acute vs gradual onset
• Duration of symptoms
• Associated symptoms
• Any related trauma

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Physical Exam

• Scrotal skin
• Edema, cellulitis, crepitus
• Testes
• Lie (bell clappers deformity?), masses, size,
  transillumination
• Spermatic cord
• Cremasteric reflex, any masses, hernia

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The Acute Scrotum

• Differential Diagnosis?
• What are the true emergencies?

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Types of Hydroceles

• Hydrocele of the testis
• Hydrocele of the Cord
• Communicating Hydrocele

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Tunica Vaginalis

• Continuous with peritoneum
• Filled with fluid Hydrocele
• Processus vaginalis is the obliterated peritoneal
  remnant above the testicle
• When obliteration does not occur you get
  communicating hydrocele
• Torsion is the testicle twisting within the T.
  Vaginalis

Tunica Vaginalis
Tunica Vaginalis
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Transillumination of Hydrocele
Place a bright focused light at base of scrotum
and turn the lights down
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Hydrocele

• Definition
• Excess fluid in a persistent processus vaginalis

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Hydrocelectomy
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Hematocele

• Collection of blood in the tunica vaginalis
• Usually caused by rupture of tunica albugenia
  from blunt or penetrating trauma
• A.k.a. scrotal hematoma
• Does not transilluminate
• Requires surgical repair of ruptured tunica
  albugenia

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Hematocele
-21 y/o pitcher for Varsity -A line drive was hit
back through the pitchers mound -He was on the
pitchers mound
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Repair of Rupture T. Albugenia
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Spermatocele

• Cyst of the epididymis
• Filled with milky-white fluid
• Physical exam
• Distinct from testicle
• Unlike hydrocele which envelopes the testicle
• Transilluminates

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Spermatocele
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Varicocele

• Varicose veins of the pampiniform plexus
• Left/Right 95/5
• Higher pressure into the left gonadal
  (testicular) vn. Is reflected down to pampiniform
  plexus
• Bag of worms
• Decreased size when supine
• May cause fertility problems due to increase
  temperature
• May result from large kidney cancer blocking the
  left gonadal (testicular) vein

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Varicocele
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VaricoceleLeft testicular venogram
Left Gonadal vn.
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Inquinal Hernia

• Reducible
• Does not transilluminate
• Hear bowel sounds

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Epididymitis

• Causes (etiology)
• Idiopathic
• ?Excessive straining
• Communicable disease
• Chlamydia
• Viral
• Mumps

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Torsion of Testicle

• Most common age is teenage year
• Adolescent to 30s
• Testicles at risk are those with a horizontal lie
• Classic history is that of a teenager with a
  sudden onset of testicular pain

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Torsion of Testicle

• Needs immediate operative repair
• Testicle can survive 6-12 hours with no blood
  supply
• Operative repair must include securing the
  ipsilateral AND contralateral testicles

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Operative Repair of Testicular Torsion
Secure t. albugenia to t. vaginalis On both sides
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Vestigial Remnants of Embryonic Genital
DuctsAppendix TestisAppendix testis is remnant
of paramesonephric (mullerian) ductAppendix
Epididymis Appendix epididymis is remnant of
mesonephric duct (wolffian)
Lateral Sulcus
Appendix Testis
Appendix Epididymis
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Torsion of Appendix Testes

• Mimics torsion of testicle
• Look for blue dot sign
• Appendix testis is remnant of paramesonephric
  (mullerian) duct
• Appendix epididymis is remnant of mesonephric
  duct (wolffian)

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Torsion of Appendix Testes
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Neoplasm Testicular Cancer

• Does not transilluminate
• Is felt to be a part of the testicle (not the
  epididymis)

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Fourniers Gangrene

• Necrotizing fasciitis of the scrotal and penile
  skin.
• Typically in diabetics, with history of urethral
  instrumentation or stricture.

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Fournier's Gangrene of Scrotum
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Fourniers Gangrene

• Still carries a 50 mortality rate.
• No good diagnostic study.
• Diagnosis made on high clinical suspicion.

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Fourniers Gangrene

• Crepitus and skin discoloration may advance
  rapidly.
• Infected tissue planes usually extend beyond what
  is visible at the skin.

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Fourniers Gangrene

• Treatment is antibiotics and immediate wide
  surgical debridement.

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Fournier's Gangrene of scrotum

• The testicles and spermatic cord are commonly
  spared
• This is due to anatomical and embryological
  differences of the scrotum and testicles

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Fourniers Gangrene

• 50 mortality
• Genital skin can later be reconstructed with STSG
  to the scrotal areas and FTSG to the penile shaft.

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Renal Trauma
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Urologic Trauma

• Any portion of the urinary system can be affected
  by blunt or penetrating trauma.
• What are the potential urologic emergencies
  related to trauma?

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Kidney-Blood Supply

• Injury to renal artery can result in loss of the
  entire kidney.
• Sudden deceleration from blunt trauma can cause
  shearing of intima, causing acute thrombosis.
• Recognized as cortical rim sign on contrast
  imaging.

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Gerotas Fascia

• 43 y/o
• I got stabbed
• Dx?
• L perinephric hematoma

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Gerotas Fascia

• 32 y/o
• Some dude shot me!
• Dx
• Right perinephric hematoma

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Gerotas Fascia

• 17 y/o
• Snowboarder vs. tree, c/o flank pain and
  microhematuria
• Dx L perinephric hematoma
• Bad jump

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Renal Trauma

• Severed vessels ligated
• Renal capsule reapproximated over bolsters

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Bladder Rupture

• Extraperitoneal
• Urine flows into the surrounding space
• Does not usually require surgery
• Catheter drainage for 7-10 days is all that is
  necessary

Contrast confined to pelvis
Cystogram
Rupture
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Bladder RuptureCommonly Associated with Pelvic
Fracture

• Intraperitoneal rupture
• Urine flows into the peritoneal cavity
• Requires emergency surgery

Rupture
Contrast around bowel
Cystogram
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Urethral Trauma

• Suspected in any trauma patient with blood at the
  urethral meatus
• Associated with pelvic fractures
• Exam may demonstrate high riding prostate
• Diagnostic study is retrograde urethrogram

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Urethral Trauma

• May occur with pelvic fracture
• Most common site is the prostate tearing away
  from the membranous urethra (urogenital diaphragm)

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Urethra Trauma Membranous Urethra
Prostate
Pubic Rami

• The membranous urethra courses through the
  urogenital diaphragm which spans between the two
  pubic rami
• The prostate is commonly sheered off of its
  attachments to the membranous urethra and rises
  upward

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Treatment

• If possible, early realignment has fewer long
  term complications.
• Due to location of injury, there is a high
  probability of recurring strictures,
  incontinence, and erectile dysfunction.

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The Endat last