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Renal Transplant

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Title: Renal Transplant


1
Renal Transplant
2
Immunology
  • ABO Match (minimum requirement)
  • HLA matching (6 Antigen Ideal)

3
Renal Transplant
  • Cadaveric (2 year wait)
  • Live Related/Unrelated (30 of Transplants)

4
Recipient Candidate
  • lt65 years of age
  • Adequate Iliac Vasculature
  • Demonstrate Compliance Medication
  • Reasonable Bladder Function

5
Organ Must Fit
  • Age Appropriate
  • Filtration Needs
  • Anatomy (PCK)

6
Polycystic Kidney Disease
7
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8
Preoperative Testing
  • Cross Match
  • UA
  • PE (CHF/UTI/URI)
  • Donor and Recipient

9
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

10
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

11
Procedure
  • Kidney Artery and Vein Are Attached to Iliac
    Vessels
  • The Ureter is Attached to the Bladder

12
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14
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

15
Immunosupression
  • Cyclosporine
  • Imuran
  • Prednisone

16
Graft Survival
  • Cadaveric 90 one year
  • Live Related 95 one year

17
Hematuria
18
Hematuria
  • Microscopic Hematuria
  • Gross Hematuria

19
Normal Urinalysis
  • No WBC
  • No RBC
  • No Protein
  • No Glucose

20
Hematuria
  • Significant if gt2-3RBC/HPF
  • Contamination (Epithelial Cells, Squamous Cells,
    Bacteria)
  • Dipstick False
  • Menstrual Period
  • Urethral Prolapse/Atrophic Vaginitis
  • Phimosis/Balanitis

21
Diagnosis
  • BPH
  • Bladder Stones
  • Renal Stone Dz
  • Cancer
  • Congenital
  • Medical Renal Dz
  • Anatomic
  • Trauma

22
Evaluation
  • Evaluate Kidneys, Ureters, Bladder, Prostate
    (men), Urethra
  • IVP/CT Scan
  • Urine Cytology
  • Cystoscopy

23
IVP
  • Bladder Tumor Filling Defects

24
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25
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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28
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

29
CASE
  • 51 y/o with L flank pain for 2 weeks and
    microscopic hematuria.

30
Non-contrast CT
?dilated ureter
31
Non-contrast CT
  • Diagnosis?

32
Stone Emergencies
  • High grade obstruction
  • Infection (particularly with obstruction)
  • Intractable pain

33
Urologic Emergencies
34
Penis
  • Phimosis
  • Paraphimosis
  • Circumcision
  • Priapism
  • Trauma

35
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
36
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
37
Paraphimosis Treatment
  • Grasp penis firmly
  • Squeeze excess fluid from the tissue distal to
    the phimotic ring

38
Paraphimosis Treatment
  • Push with thumbs
  • Pull with index finger

39
Paraphimosis Treatment
  • Plan elective circumcision

Uncircumcised 15 y/o
Phimotic Ring
40
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

41
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.

42
Treatment Options
  • Penile irrigation/aspiration
  • Shunting procedures

43
Interesting Cases
  • 32 y/o male having sexual intercourse
  • Felt and heard a snap
  • Immediately loss erection
  • Penis became swollen

44
Interesting cases
  • 35 y/o male weight lifter
  • Looking for more weighty erection

45
Interesting Cases
  • 28 y/o mechanic
  • Rebuilds engines
  • Dissatisfied with sexual prowess
  • Considers himself ingenuous and resourceful
  • Comes in with an obvious complaint

46
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.

47
History
  • Characterize the pain
  • Acute vs gradual onset
  • Duration of symptoms
  • Associated symptoms
  • Any related trauma

48
Physical Exam
  • Scrotal skin
  • Edema, cellulitis, crepitus
  • Testes
  • Lie (bell clappers deformity?), masses, size,
    transillumination
  • Spermatic cord
  • Cremasteric reflex, any masses, hernia

49
The Acute Scrotum
  • Differential Diagnosis?
  • What are the true emergencies?

50
Types of Hydroceles
  • Hydrocele of the testis
  • Hydrocele of the Cord
  • Communicating Hydrocele

51
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
52
Transillumination of Hydrocele
Place a bright focused light at base of scrotum
and turn the lights down
53
Hydrocele
  • Definition
  • Excess fluid in a persistent processus vaginalis

54
Hydrocelectomy
55
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

56
Hematocele
-21 y/o pitcher for Varsity -A line drive was hit
back through the pitchers mound -He was on the
pitchers mound
57
Repair of Rupture T. Albugenia
58
Spermatocele
  • Cyst of the epididymis
  • Filled with milky-white fluid
  • Physical exam
  • Distinct from testicle
  • Unlike hydrocele which envelopes the testicle
  • Transilluminates

59
Spermatocele
60
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

61
Varicocele
62
VaricoceleLeft testicular venogram
Left Gonadal vn.
63
Inquinal Hernia
  • Reducible
  • Does not transilluminate
  • Hear bowel sounds

64
Epididymitis
  • Causes (etiology)
  • Idiopathic
  • ?Excessive straining
  • Communicable disease
  • Chlamydia
  • Viral
  • Mumps

65
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

66
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

67
Operative Repair of Testicular Torsion
Secure t. albugenia to t. vaginalis On both sides
68
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
69
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)

70
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)

75
Fourniers Gangrene
  • Necrotizing fasciitis of the scrotal and penile
    skin.
  • Typically in diabetics, with history of urethral
    instrumentation or stricture.

76
Fournier's Gangrene of Scrotum
77
Fourniers Gangrene
  • Still carries a 50 mortality rate.
  • No good diagnostic study.
  • Diagnosis made on high clinical suspicion.

78
Fourniers Gangrene
  • Crepitus and skin discoloration may advance
    rapidly.
  • Infected tissue planes usually extend beyond what
    is visible at the skin.

79
Fourniers Gangrene
  • Treatment is antibiotics and immediate wide
    surgical debridement.

80
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

81
Fourniers Gangrene
  • 50 mortality
  • Genital skin can later be reconstructed with STSG
    to the scrotal areas and FTSG to the penile shaft.

82
Renal Trauma
83
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?

84
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.

85
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86
Gerotas Fascia
  • 43 y/o
  • I got stabbed
  • Dx?
  • L perinephric hematoma

87
Gerotas Fascia
  • 32 y/o
  • Some dude shot me!
  • Dx
  • Right perinephric hematoma

88
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92
Gerotas Fascia
  • 17 y/o
  • Snowboarder vs. tree, c/o flank pain and
    microhematuria
  • Dx L perinephric hematoma
  • Bad jump

93
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96
Renal Trauma
  • Severed vessels ligated
  • Renal capsule reapproximated over bolsters

97
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
98
Bladder RuptureCommonly Associated with Pelvic
Fracture
  • Intraperitoneal rupture
  • Urine flows into the peritoneal cavity
  • Requires emergency surgery

Rupture
Contrast around bowel
Cystogram
99
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

100
Urethral Trauma
  • May occur with pelvic fracture
  • Most common site is the prostate tearing away
    from the membranous urethra (urogenital diaphragm)

101
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.

104
The Endat last
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