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. Clinicalfindings: 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. Clinicalfindings: 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.
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