50Case AA 55-year-old woman was found rolling on her kitchen floor, crying out from agonizing pain in her abdomen. The pain came in waves and extended from the right loin to the groin and to the front of the right thigh. An anteroposterior radiograph of the abdomen revealed a calculus in the right ureter.
51Question What causes the pain when a ureteral calculus is present? Why is the pain felt in such an extensive area?Where does one look for the course of the ureter in a radiograph?Where along the ureter is a calculus likely to be held up?
52Case BAn explorer in the Amazon jungle was found alive after having lost contact with the outside world for six months. On physical examination, he was found to be in an emaciated condition. On palpation of the abdomen, a rounded, smooth swelling appeared in the right loin at the end of inspiration. On expiration, the swelling moved upward and could no longer be felt. What anatomical structure could produce such a swelling?
53Case CAn intravenous pyelogram revealed that a patient’s left kidney was in its normal position, but the right kidney was situated in front of the right sacroiliac joint. Can you explain this on embryological grounds?
54Case DAn examination of a patient revealed that she had a horseshoe kidney. What anatomical structure prevents a horseshoe kidney from ascending to a level above the umbilicus?
55Case EAn intravenous pyelogram revealed that the calyces and pelvis of a patient’s right kidney were grossly dilated (a condition known as hydronephrosis). What embryological anomaly may be responsible for this condition?
56Case FWhich congenital anomaly of the ureter is likely to present as a case of urinary incontinence?
58nephrectomyFor a nephrectomy, the kidney commonly is exposed in the loin. After an oblique incision midway between the twelfth rib and the iliac crest, the posterior free border of the external oblique is identified, and divided to reveal the peritoneum, which is pushed forward to reveal the renal fascia. The subcostal nerve and vessels are preserved; the renal fascia is opened; and the kidney exposed. Care must be taken not to damage the pleura, since it is separated from the upper pole of the kidney only by the diaphragm.Posterior surgical approachSince the kidneys lie in part above the twelfth rib, a direct posterior approach might pass first into the thorax, perforating the pleural cavity. A posterior approach to the kidney also puts at risk the subcostal and iliohypogastric nerves which pass laterally behind the kidney.