Obstructive Uropathy "online"
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Lecture for students of October 6th Uni. Faculty of Medicine. 6th Grade
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Obstructive Uropathy "online"
- 1. Obstructive Uropathy By Ayman Rashed, MD Lecturer of Urology
- 2. General Principles Obstructive Uropathy Signifies any obstruction that occurs anywhere in the urinary tract. It is associated with changes in the urinary system above the level of obstruction
- 3. Classification Obstruction can be divided according to: Acute or chronic obstruction Partial or complete obstruction Unilateral or bilateral obstruction Congenital or acquired obstruction Extrinsic or intrinsic obstruction Etiological (according to the cause of obstruction)
- 4. Etiological (according to the level of obstruction) Renal causes 1. Kidney stones 2. Congenital PUJO 3. Aberrant renal vessels 4. Renal pelvic tumors 5. Tuberculous stricture Ureteric causes 1. In the lumen, e.g., stones and blood clots 2. In the wall 1. Congenital atresia and ureterocele 2. Ureteric stricture 3. Tumors (intrinsic or extrinsic) 3. Outside the lumen (compression) 1. Infiltration by carcinoma of the cervix, colon, or rectum 2. Idiopathic retroperitoneal fibrosis (1)(2) (3)
- 5. Urinary bladder causes 1. Tumors involving ureterovesical junction 2. Neurogenic bladder dysfunction Bladder neck causes 1. Impacted Stone 2. Congenital bladder neck obstruction 3. Bilharzial bladder neck obstruction 4. Bladder neck tumors Prostate causes 1. Benign prostatic hyperplasia (BPH) 2. Cancer prostate 3. Acute Prostatitis Urethral causes 1. Congenital: e.g. meatal stenosis and posterior urethral valves 2. Stricture of the urethra
- 6. Pathology Urethra Increased hydrostatic pressure leads to urethral dilatation above the obstruction Urinary bladder Early, (Compensated Phase): Hypertrophy of the detrusor muscle --- bladder Trabeculation --- Saccules (mucosa protrudes between muscle fibers) --- Diverticulae develop when mucosa bulges outside bladder wall Later, (Decompensated Phase): the bladder dilates more and its wall thins out --- Atony of the bladder --- Urinary retention Ureter Early there is muscular hypertrophy of the wall, later atony occurs. The ureter becomes dilated (hydroureter), elongated and tortuous
- 7. Kidney • Morphological changes: Normally, the pressure within the renal pelvis is close to zero. With obstruction this pressure increases and pelvicalyceal system dilates leading to hydronephrosis 1. In early stages, Renal pelvic musculature undergoes compensatory hypertrophy. Later, muscles become stretched and atonic (decompensated) 2. Calyces are the first to suffer from obstruction. The normal concave appearance (cupping) of minor calyces , becomes flat then rounded (clubbing) and lastly ballooned 3. Renal parenchyma starts to thin out as it suffers from ischaemic atrophy as it is compressed between renal capsule externally, and the centrally increasing intra-pelvic pressure 4. At a later stage, the kidney is completely destroyed and appears as a thin-walled sac filled with clear fluid or, if infected, with pus
- 8. IVP: Bilateral Hydro-uretero-nephrosis Due to Bilateral Ureteric Stricture
- 9. Functional changes 1. Intra-pelvic pressure continues to rise till it overcomes the glomerular filtration pressure, where urine secretion stops 2. Glomerular filtration rate and the renal plasma flow are reduced and renal concentrating power is gradually lost 4. The contralateral normal kidney undergoes compensatory hypertrophy in order to maintain an overall normal renal function 5. In neglected bilateral obstruction, renal failure will occur
- 10. With relief of obstruction Early treatment leads to remarkable improvement of morphology and function Delay in treatment results in some degree of irreversible renal damage Factors affecting morphological and functional changes 1. Level of obstruction (proximal or distal “uni or bilateral”) 2. Degree of obstruction (complete or incomplete) 3. Duration of obstruction. Long-standing partial or intermittent obstruction tends to produce significant proximal dilatation. Acute obstruction, on the other hand, tends to produce mild dilatation but more rapid deterioration of function 4. Infection on top of obstruction
- 11. Complications 1. Stasis means infection --- faster deterioration of renal function 2. Stone formation 3. Rupture of hydronephrotic kidney (rare, with trauma) 4. Renal failure in bilateral cases Urgent Acute Obstructive Conditions Acute Urinary Retention Calcular Anuria Bilateral ligation of both ureters
- 12. Hydronephrosis Definition Hydronephrosis is chronic aseptic distension of the renal pelvis and calyces due to obstruction of the urinary tract Aetiology 1. All causes of chronic obstructive uropathy 2. Pregnancy: especially on the right side. Dilatation occurs during the first few weeks and reaches maximum between fifth and sixth month. It is due to atony of ureteric musculature due to high progesterone level. Also, the fetal head may compress both ureters. Hydronephrosis of pregnancy subsides within 2-12 weeks after delivery 3. Vesicoureteric reflux
- 13. Normal IVU
- 14. Bilateral Hydronephrosis due to Pregnancy near term
- 15. Carcinoma of the colon invading the right ureter An antegrade pyeloureterogram shows a ureteral stent
- 16. Hydronephrosis in U/S Normal Kidney in U/S
- 17. Clinical features 1. Pain: There is usually slight dull aching pain or a sense of discomfort in the loin 2. Swelling: In late stages a cystic swelling in renal angle 3. Polyuria of low specific gravity 4. Manifestations of renal failure, if present Complications: As mentioned in general principles Differential diagnosis: Polycystic kidney Hypernephroma
- 18. Investigations 1. Urine analysis for RBCs, WBCs, SG and crystals 2. Ultrasound examination to detect renal size, thickness of the renal cortex (parenchyma) and possibly the cause, e.g., stones 3. IVU will show the following: Dilatation of renal pelvis which becomes biconvex Pelviureteric junction is distorted and is raised upwards Loss of cupping, and clubbing and later ballooning of the minor calyces Delayed excretion of contrast. In advanced cases no secretion occurs 4. Ascending (retrograde) pyelography. If IVU does not give conclusive data, ascending pyelography is indicated to confirm the diagnosis 5. Descending (antegrade) pyelography is sometimes done if a nephrostomy tube is present
- 19. Normal Bilateral Ascending (retrograde) Pyelography
- 20. Treatment Removing cause of obstruction Nephrectomy in selected cases The kidney is non functioning with infusion urography Sonography showed very thin parenchyma Renal scan shows zero function The opposite kidney is normal In compromised cases with bad other kidney, a percutaneous nephrostomy may be left for long time till obstruction is treated In advanced cases of PUJO --- Pyeloplasty to provide adequate drainage of the lowest part of the pelvis
- 21. Ureteric Stricture Aetiology 1. Congenital: PUJO or UVJO (pin-hole meatus) 2. Traumatic: Following ureteric injuries e.g. Iatrogenic 3. Inflammatory 4. Bilharzial stricture: commonly affects the intramural and lower part of the ureter. It may be bilateral 5. Tuberculous stricture: affects the whole ureter and is usually multiple and bilateral 6. Long-standing stone may lead to stricture 7. Neoplastic: Carcinoma of the ureter (intrinsic) or more often, invasion of ureter (extrinsic) by a malignant growth as carcinoma of the uterus, colon, or rectum
- 22. Clinical features 1. Renal pain (dull aching) due to distension of the renal pelvis 2. Progressive hydronephrosis 3. Recurrent attacks of pyelonephritis 4. In Egypt, bilateral hydronephrosis is a common sequel of bilateral Bilharzial ureteric stricture. These patients may present by chronic renal failure Investigations 1. Blood urea, serum creatinine and serum electrolytes 2. U/S will demonstrate hydronephrosis 3. IVU will determine site of the stricture and degree of functional capacity of both kidneys 4. Retrograde and Antegrade pyelography
- 23. Treatment (mainly surgical) Stricture of upper 2/3 (above the level of ischial spine) Excision and end-to-end anastomosis: Both ends of the ureter are trimmed obliquely, spatulated and then anastomosed by interrupted sutures of 4-0 Vicryl over a ureteric stent which is removed later by a cystoscopic forceps Stricture of lower 1/3 Ureterovesical reimplantation: The ureter is divided above the stricture and then a new ureterovesical anastomosis is established.. Bladder (Boari's) flap: for long stricture. A flap can be prepared from the bladder wall, transformed into tube and anastomosed to ureter Stricture of long segment of ureter: Ileal loop replacement
- 24. Pre- and Post- Dismembered Pyeloplasty for PUJO
- 25. Retroperitoneal Fibrosis Types Primary (idiopathic) retroperitoneal fibrosis Unknown aetiology but may be drug-induced, e.g., methysergide that is used for prophylaxis against migraine The patient may presents acutely with anuria. Ureteric catheterization is urgently done to relieve obstruction. Unlike calcular anuria, the catheters pass up to the kidneys easily. ESR, urea and creatinine are usually elevated. IVU and/or ascending pyelography demonstrates that both ureters are pulled medially towards the mid line. CT shows a retroperitoneal fibrous plaque in which both ureters and great abdominal vessels (aorta an IVC) are embedded. Both kidneys show hydronephrotic changes. Definitive treatment is Surgical Ureterolysis i.e. release of ureters from fibrous tissue, then wrapping them in pedicled omentum inside the peritoneal cavity to avoid re-obstruction. Postoperative corticosteroid therapy is believed to reduce the possibility of recurrence Secondary retroperitoneal fibrosis Diffuse infiltrating retroperitoneal malignancy Previous leakage of an aortic aneurysm
Editor's Notes
- This is Dr. Ayman Rashed, Urology department. and this is the first online narrated Urologic lecture for students of 6th Grade at faculty of medicine, October 6th University. today’s lecture “ Obstructive Urology” is the keynote of Urology by which you can understand most of Urology, that is why I prefer to start with
- what is meant by Obstructive Uropathy? this is to signify any obstruction that occurs anywhere in the urinary tract from the kidneys above through ureters down to the urinary bladder and finally out of the body through the urethra. It is associated with changes in the urinary system above the level of obstruction for example dilatation. the picture in this slide denoting IVP of normal appearance of the urinary system. you can see obviously the collecting system with cupping, normal renal pelvis on both sides, normal caliber of ureters and normal filling of the bladder. by the way this is incomplete film because the urethra couldn’t be shown in this film
- the obstruction can be classified according to the following Is it Acute or chronic Partial or complete Unilateral or bilateral Congenital or acquired Extrinsic or intrinsic Etiological (according to the cause of obstruction)
- according to etiology will further subdivided according to the level of obstruction. so, at the renal level etiology may be due to: Renal stones, Congenital PUJO, Aberrant renal vessels, Renal pelvic tumors, Tuberculous stricture. at this level you will note dilatation of the collecting system what we call Hydronephrosis as appeared in IVP film No. (1) where the obstruction at the level of renal pelvis red arrow mostly due to congenital pelvi-ureteric junction obstruction (PUJ) when the ureter is obstructed at any level it will cause dilatation including the ureter above the obstruction and the kidney or the collection system what we call hydrouretronephrosis. This may be due to causes inside the the ureteric lumen like stones as in film No. (2) red arrow or blood clots or causes in the wall of the ureter as ureteric stricture as in film No. (3) showing bilateral hydrouretronephrosis due to bilateral ureteric strictures (red arrows, atresia, uretrocele
- at the urinary bladder level the causes of obstruction may include : Impacted stone at bladder neck, Tumors involving ureterovesical junction or Neurogenic bladder dysfunction. at the level of the prostate: BPH Cancer prostate or even Acute prostatitis can cause obstruction. as you see in the picture this an IVP film denoting a filling defect due to enlarged prostate (red arrows) note the smooth edge of the filling defect of the prostate that elevating the bladder upward causing outlet obstruction and the diverticulum on the left side of the bladder (yellow arrow) due to increased pressure inside the bladder. finally at the level of the urethra the obstruction may be due to Congenital: e.g. meatal stenosis and posterior urethral valves or due to Stricture of the urethra
- Now what are the pathologies resulted as a consequence of the obstruction as regard to the urethra it is just a dilatation above the level of obstruction. As regard to the urinary bladder: the pathology occurred subdivided to Early (Compensated Phase): where Hypertrophy of the detrusor muscle --- bladder Trabeculation --- Saccules (mucosa protrudes between muscle fibers) --- Diverticulae develop when mucosa bulges outside bladder wall as we just have seen in the previous slide IVP film. then Later (Decompensated Phase): when the bladder couldn’t contract anymore against the obstruction the bladder dilates more and its wall thins out --- Atony of the bladder --- Urinary retention As regard to the Ureters. they take the same way as the Bladder
- The renal pathology will suffer from obstruction Morphologically and functionally the morphologic changes will occur due to elevated hydrostatic pressure inside the collecting system (from normally zero) leading to hydronephrosis. the severity of the changes depends upon many factors that we will discuss later. So, in early stages the renal pelvis musculature undergoes compensatory hypertrophy. Later, muscles become stretched and atonic (decompensated) The Calyces are the first to suffer from obstruction. The normal concave appearance (cupping) of minor calyces , becomes flat then rounded (clubbing) and lastly ballooned Renal parenchyma starts to thin out as it suffers from ischaemic atrophy as it is compressed between renal capsule externally, and the centrally increasing intra-pelvic pressure At a later stage, the kidney is completely destroyed and appears as a thin-walled sac filled with clear fluid or, if infected, with pus
- this is an IVP film: an example for hydrouerteronephrosis due to bilateral lower ureteric stricture (red arrows). Note the clubbing of the calyces more evident on Lt side (yellow arrows)
- the functional changes include stopping of urine secretion due to increased intra-pelvic pressure which at some point will overcome the glomular filtration pressure this will subsequently reduce the filtration rate and reduce the concentrating power of the kidney. the contralateral normal kidney undergoes compensatory hypertrophy in order to maintain an overall normal renal function. In neglected bilateral obstruction, renal failure will occur
- Early treatment leads to remarkable improvement of morphology and function, while Delay in treatment results in some degree of irreversible renal damage. the factors affecting the degree of renal changes include 1. Level of obstruction (proximal or distal “uni or bilateral”) 2. Degree of obstruction 3. Duration of obstruction. Long-standing partial or intermittent obstruction tends to produce significant proximal dilatation. Acute obstruction, on the other hand, tends to produce mild dilatation but more rapid deterioration of function 4. Infection on top of obstruction
- the complications of urinary obstruction include 1. Stasis means infection --- faster deterioration of renal function 2. Stone formation 3. Rupture of hydronephrotic kidney (rare, with trauma) 4. Renal failure in bilateral cases and the emergency conditions are Acute Urinary Retention where the urine couldn’t expelled out of the bladder Calcular Anuria where the obstruction above the level of the bladder and the urine cannot reach down to the bladder Bilateral ligation of both ureters is another example of anuria
- Hydronephrosis as a separate entity. means chronic aseptic distension of the renal pelvis and calyces due to obstruction of the urinary tract, so it is a manifestation of a hidden disease and a diagnosis Aetiology 1. All causes of chronic obstructive uropathy commonly due to stones within the urinary tract 2. Pregnancy: especially on the right side. Dilatation occurs during the first few weeks and reaches maximum between fifth and sixth month. It is due to atony of ureteric musculature due to high progesterone level. Also, the fetal head may compress both ureters. Hydronephrosis of pregnancy subsides within 2-12 weeks after delivery 3. Vesicoureteric reflux
- This is again normal IVP showing normal urinary system
- this is an IVP done by mistake elsewhere for a pregnant woman near full term. the fetal sac shadow appeared to bilaterally obstructing the urinary system (compression from outside) resulting in bilateral Hydroureteronephrosis. of course it is a temporary condition which relieved after labor.
- this is an antegrade pyelography study showing the nephrostomy tube (red arrows) inside the kidney and the contrast media was injected through this tube to assess the morphology of the Rt. kidney which is obstructed by cancer colon invading the ureter. in such cases we try to maintain the kidney function and patency of the tract by inserting a ureteric stent (yellow arrows) or by directing the urine directly outside by nephrostomy tube (red arrow)
- here in you can see normal Renal U/S above and hydronephrosis in the below picture. Note the difference between normal calyces (yellow arrows) and dilated calyces (red arrows). Also note, renal capsule (black arrows) and Renal parenchyma (green arrows)
- clinical features include: dull aching pain due to stretch of renal capsule, swelling can be palpated in late stages as a cystic swelling in renal angle. lab investigations may reveal polyuria with low specific gravity due to loss of concentration power and elevated serum urea and creatinine in bilateral renal hydronephrosis cases denoting renal failure Dx include polycystic kidney and hypernephroma both can be investigated using U/S and CT
- these are the investigations that should be done to reveal the etiology of Hydronephrosis
- this a Retrograde or ascending pyelography study showing the cystoscope (red arrows) introduced through the urethra inside the bladder and two ureteric catheters (yellow arrows) advanced in both ureters though which contrast media is injected to delineate the urinary tract. this is a morphologic study by which you can study the anatomy of urinary tract but not functional study as you inject the contrast media not secreted by the kidney unlike in IVP which assess morphologic and functional parameters of the urinary tract
- of course treatment will depend on treatment of the cause for example removing obstructing stones. however in some cases with end stage non functioning kidney the nephrectomy may be the treatment of choice. In compromised cases with bad other kidney, a percutaneous nephrostomy may be left for long time till obstruction is treated In advanced cases of PUJO --- Pyeloplasty to provide adequate drainage of the lowest part of the pelvis
- Stricture is also another separate entity and also is a manifestation for hidden etiology which may be one of the following Congenital: PUJO or UVJO (pin-hole meatus) Traumatic: Following ureteric injuries e.g. Iatrogenic Inflammatory Bilharzial stricture: commonly affects the intramural and lower part of the ureter. It may be bilateral Tuberculous stricture: affects the whole ureter and is usually multiple and bilateral Long-standing stone may lead to stricture Neoplastic: Carcinoma of the ureter (intrinsic) or more often, invasion of ureter (extrinsic) by a malignant growth as carcinoma of the uterus, colon, or rectum
- this is an example for PUJ obstruction on Lt picture and after excision of the strictured part of the ureter (red arrow) and repair on the rt picture
- here in you can see ascending pyelography showing straightening of the Lt ureter and its shifting toward spinal column also hydronephrosis is noted these features denoting retroperitoneal fibrosis