Stones - Symptoms: loin pain, hematuria, passage of stones, fever - Specific questions: (4) familiy history, past history,

diet, lifestyle Tumors: (1) Benign: angiomyolipoma (AML) - Presentation: loin pain, or rupture (20% as shock in A&E due to retroperitoneal hemorrhage) - Diagnosed b/c of FAT: U/S (prelim but not gold standard) or CT - Associated with tuberous sclerosis (may have multiple AML per kidney) and lymphangioleiomyomatosis (LAM). AML may also be found in liver (less common). - Indications for surgery due to risk of hemorrhage >4 cm Female, fertile, forty - Treatment Surgery: partial nephrectomy Ablation: RFA/ cryotherapy Interventional Radiology: Embolization (particularly in ruptured cases; may have post-embolization syndrome: pain, fever, fatigue for a few days: no treatment needed) (2) Malignant: RCC (most common) - ALERT in chronic smoker, industrial exposure (asbestos, lead, cadmium) - Presentation Large tumors: Classical triad (<10% present with all three, usually only in large tumors): flank pain, flank mass, hematuria Small: incidentalomas *solid renal masses should be considered malignant until proven otherwise - Diagnosis: (1) CT/ MRI ideal for renal masses: need non-contrast + contrast enhanced study. Look for irregular/ lobulated margins, malignant cysts, 10% calcifications and (2) +/- Doppler US for renal vein and vena cava (3) CXR for mets +/- Bone scan in patients with bone-related complaints Dont need routine USG biopsy if there are typical radiological findings - Considered most lethal of all urological cancers - Clear cell (60-70%), Papillary (10-15%), Chromophobe (3-5%; cell origin: intercalated cell of cortical collecting duct) - TNM Staging Stage I: T diameter <7cm + limited to kidney N0M0

Stage II: T diameter > 7cm + limited to kidney. N0M0 Stage III: several combinations of T and N categories. Essentially: variable tumor size and local invasion, but involves ONE nearby lymph node, no distant LN. No Metasasis. Stage IV: Several combinations of T,N,M. Note: T3: Tumor extends into major veins/adrenal/ perinephric tissue; not beyond Gerota's fascia; T4: Tumor invades beyond Gerota's fascia Most common metastasis: Lymph node, lung, bone, brain (renal drains directly into IVC, will not pass by liver) Treatment Surgery: T1: nephron-sparing surgery via partial nephrectomy T2: nephron sparing surgery if possible, or radial nephrectomy T3,4: radical nephrectomy Resistant to C/RT. Targeted therapy (eg sorafenib) or immunotherapy (eg IL2) has survival benefit

Renal Cyst - 50% of people older than 50 years old have renal cysts - Bosniak Grading based on radiological findings Bosniak I, II: non-contrast enhancing absolutely no risk of malignancy, do not need further imaging or F/U Bosniak IIF: multiple non-enahancing hairline septa sometimes with nodular or thick calcifications. 5-20% malignant: need serial imaging, thus intermittent F/U Bosniak III: indeterminate lesions with thick/ irregular septa, with enhancement. 50% malignant potential Bosniak IV: cysts that have >90% malignancy potential - Management I,II: no F/U needed IIF: intermittent F/U III, IV: surgical management Renal Transplantation - Criteria for Living Related Donor: (1) first-degree relative OR couple for >=1

year (2) no infectious disease (3) healthy kidney (4) ? ABO compatibility Special donor pre-existing conditions Cyst: I,II suitable for transplantation; others: not Stone: not preferred due to likelihood of recurrence in donor Vascular variants in left kidney: right open surgery to trace right renal A/V (not possible in laparoscopy) Laparoscopy: usually harvests left kidney since laparoscopy does not allow tracing of right vessels (much shorter! Makes the anastomosis in recipient more technically difficult) Transperitoneal Approach: pro: spacious, better appreciation of anatomy; con: paralytic ileus Retroperitoneal Approach: vice versa, shorter hospital stay due to less paralytic ileus Risk of donor: Renal hypertrophy as compensation, leading to higher chance of hypertension Surgical procedure highlight: trace left gonadal vein to find the renal hilum (which contains the VAU anterior to posterior): left gonadal vein left renal vein; Right gonadal vein IVC -

Surgical Anatomy: Kidney Renal Capsule Perirenal Fat Gerotas/ Renal Fascia Pararenal Fat Lienorenal fascia??