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Obstructive Uropathy in Neonate
Dr. Shirish Silwal &
Dr. Md. Saiful Islam
Phase A Resident
Dept. of Paediatric Surgery
Case Scenario
• Male preterm 36 weeks baby antenataly diagnosed as left
sided hydroureteronephrosis admitted in NICU with
...
Discussion
Obstructive Uropathy
• The structural or functional disorder leading to
impaired urinary flow.
• The obstruction may be in...
AETIOLOGY
CALYX
• Hydrocalycosis
• Myocalycosis
• Calyceal diverticulum
PELVIC URETERIC JUNCTION OBSTRUCTION
URETER
• Uret...
BLADDER
• Urolithiasis
• Neurogenic bladder
URETHRA
• Posterior urethral valve
• Posterior urethral cyst
• Congenital hype...
PRENATAL HDN
• Posterior Urethral Valves (10%)
• Ureteropelvic junction obstruction
• Multicystic Dysplastic Kidney
• Mega...
General concept
concerning obstructive uropathy
Affects all ages and has …varied presentations
PRESENTATION
• Will depend on the site, the degree of
obstruction and the duration.
TREATMENT PRINCIPLES
BE LOGICAL IN APPROACH
• Relieve Obstruction
• Correct the derangements
that may have occurred.
• Tre...
Posterior Urethral Valve
Literary History
1717. Morgagni, first to report a description of PUVs.
1802. However, the most frequently referenced, earl...
Introduction
Definition:
Posterior Urethral Valves are mucosal folds at the distal prostatic
urethra that cause varying de...
Epidemiology
• PUV affects exclusively in male infants
• Occurs in about 1 : 8,000 births
• Elevated incidence in African-...
Normal anatomy of urethra
Young Classification
Type I valves (95%)
– Represents sail-like folds from the verumontanum distally along the
urethra
– T...
Young Classification
Type II valves
– Extend proximally from the verumontanum to the bladder neck.
– Likely have only hist...
Young Classification
Type III valve (5%)
– Circular diaphragm distal to the verumontanum at the level of the
membranous ur...
Presentation
Variable & Age dependent
• Prenatally : 70% of PUV by Ultrasound
• Newborns: Abdominal mass
Ascites
Respirato...
Pathophysiology
Embryological defect causing Lower Urinary Tract Obstruction (LUTO)
Oligohydramnios
Increased vesical pres...
Diagnosis
• Most commonly made by screening antenatal USG
• Neonatal physical exam may demonstrate a palpable
hypertrophie...
Investigations
UltraSound is usually the first diagnostic tool
– bilateral hydroureteronephrosis
– a large, thick-walled b...
Postnatal Management
Includes:
• Stabilization of the patient
• Drainage of the urinary tract
• Correction of electrolyte ...
Postnatal Management
Drainage of Urinary Bladder
1. Placement of a catheter in the bladder
• Temporary
• Until patient sta...
Postnatal Management
Drainage of Urinary Bladder
2. Primary ablation during cystoscopy
• Preferred initial surgical treatm...
Postnatal Management
Drainage of Urinary Bladder
3. Vesicostomy
• performed in infants in whom safe visualization or ablat...
Postnatal Management
Drainage of Urinary Bladder
4. Higher diversions
• Cutaneous ureterostomies and pyelostomies are rare...
Post-procedure Management
Starts after a successful procedure that relieves or bypasses the
intervention
1. Detecting and ...
Outcome
Despite prenatal diagnosis and early intervention, a significant
number of patients will develop
 ESRD
 Persiste...
Follow-up
MCUG at 2 months after treatment to ensure destruction of
valves
Regular USG to evaluate resolution of HDN
Ongoi...
Prognosis
• Late Presentation, Cr > 1.0 after 1 month of treatment, Type
III PUV all have worse prognosis
• 30 % cases dev...
Conclusion
• Type I is the most commonest.
• USG and MCUG are the modalities of diagnosis
• Drainage, Antibiotics and corr...
Journal
Ureteropelvic Junction
Obstruction
Definition
• A ureteropelvic junction (UPJ) obstruction can be considered a
restriction to flow of urine from the renal pe...
Epidemiology
• UPJ obstruction is the most common cause of significant
dilation of the collecting system in the fetal kidn...
Etiology
• Intrinsic:
Narrowed, dysfunctional or adynamic segments.
• Extrinsic:
Upper ureter is angulated, kinked or comp...
Intrinsic obstruction
• Mechanical: narrowed →
incomplete embryological
ureteric bud recanalization;
muscular invagination...
Extrinsic obstruction
• Vessel or fibrous band
may pass anterior to the
pelvis & ureter: most
common.
• May secondary to
i...
Symptoms & Signs
• Asymptomatic
• Insidious onset of pain
• Sensation of draggaing heavyness that worsen by excessive
flui...
Diagnosis
• Prenatal Ultrasound
• Excretion urography
• CT scan
• MR urography
• Isotope renography :
A)DTPA(Diethylenetri...
Figure: These neonatal ultrasound images come from infants with a history of prenatally detected renal dilation. (A)
This ...
Management
• Medical Mx: Focused on
a) Maintaining sterile urine.
b) Assessing renal function and the degree of
hydronephr...
Management (Continued…)
• Surgica Mx:
Principles are:
• Formation of a funnel
• Dependent drainage
• Watertight anastomosi...
Vesicoureteric reflux
Vesicoureteric reflux
• VUR refers to the retrograde passage of urine from
the bladder into the ureter.
 38% of children ...
• Primary Vesicoureteric Reflux:
Main reason for it is a fundamental deficiency
in the function of the UVJ antireflux mech...
Figure: Components of the competent ureterovesical junction. Those abnormalities
most often implicated in the etiology of ...
International Reflux Study in Children
classification system
 Grade I reflux into a non-
dilated ureter.
 Grade II reflu...
Surgical Indications
 Breakthrough UTI during antibiotic prophylaxis.
 Anatomical abnormalities:
– Periureteric bladder ...
Various operative options
Subtrigonal injection
Extravesical detrusorrhaphy
Advancement - detrusor closure, urothelial clo...
URETHRAL STRICTURE
• Exclusively in males
1. Congenital
2. Infections
– secondary to urethritis by catheter
3. Traumatic
–...
• Present with urinary retention
• Diagnosis – suspected from history and PE
• IVU, retrograde urethrography (helpful)
• E...
MEATAL STENOSIS
• Usually as a result of previous episodes of meatitis by
ammoniacal inflammation.
• Associated with balan...
PHIMOSIS
• Inability to retract foreskin.
• Neonate – physiologic due to
natural adhesions between
prepuce & the glans.
• ...
Some Important Investigation
Plain Abdominal Radiography
1) as a primary study
2) as a scout film in anticipation of contr...
Micturating cystourethrogram
1. Evaluation of structural and functional bladder outlet
obstruction
2. Evaluation of reflux...
Retrograde urethrogram
1 Evaluation of ureteral stricture disease
2 Assessment for foreign bodies
3 Evaluation of penile o...
Intravenous urography
• Demonstrate the renal collecting systems and ureters
• Investigate the level of ureteral obstructi...
Cystourethroscopy
1. Rigid
2. Flexible
Indication
• Cystourethroscopy is used to directly visualize the anterior
urethra, ...
Thank You
Obstructive uropathy in neonates
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Brief descriptions about all categories of obstructive uropathies.

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Obstructive uropathy in neonates

  1. 1. Obstructive Uropathy in Neonate Dr. Shirish Silwal & Dr. Md. Saiful Islam Phase A Resident Dept. of Paediatric Surgery
  2. 2. Case Scenario • Male preterm 36 weeks baby antenataly diagnosed as left sided hydroureteronephrosis admitted in NICU with complain of respiratory distress . • Postnatal USG reveled B/L hydronephrosis ? PUV with trabeculated and thick bladder wall. • Serum creatinine 2.94mg/dl • So paediatric nephrology and pediatric surgery consultation done. • Planned for catherterization on 3rd day followed by • Cutaneous Vesicostomy done on 21st day under GA
  3. 3. Discussion
  4. 4. Obstructive Uropathy • The structural or functional disorder leading to impaired urinary flow. • The obstruction may be in the upper or lower urinary tracts. • Will have corresponding signs and symptoms based on the site, degree of obstruction and duration.
  5. 5. AETIOLOGY CALYX • Hydrocalycosis • Myocalycosis • Calyceal diverticulum PELVIC URETERIC JUNCTION OBSTRUCTION URETER • Ureterocele • Retrocolic ureter or aberrant • vessel obstruction • Ureteric strictures • Ureteric valve • Diverticulum • Distal ureteral atresia
  6. 6. BLADDER • Urolithiasis • Neurogenic bladder URETHRA • Posterior urethral valve • Posterior urethral cyst • Congenital hypertrophy of verumontanum • Anterior urethral valve • Urethral stricture • Meatal stenosis OTHERS • Tumours • Phimosis • Damage to sacral roots S2,S4(myelomeningocele)
  7. 7. PRENATAL HDN • Posterior Urethral Valves (10%) • Ureteropelvic junction obstruction • Multicystic Dysplastic Kidney • Megaureter • Vesicoureteric Reflux • Ureteral Ectopia • Ureterocele Ectopic • Prune Belly Syndrome • Urethral atresia • Pelvic Tumor • Cloacal Anomaly
  8. 8. General concept concerning obstructive uropathy Affects all ages and has …varied presentations
  9. 9. PRESENTATION • Will depend on the site, the degree of obstruction and the duration.
  10. 10. TREATMENT PRINCIPLES BE LOGICAL IN APPROACH • Relieve Obstruction • Correct the derangements that may have occurred. • Treat any infection • Sort out the primary cause of the problem THE ANSWER MAY NOT BE STRAIGHT
  11. 11. Posterior Urethral Valve
  12. 12. Literary History 1717. Morgagni, first to report a description of PUVs. 1802. However, the most frequently referenced, earliest description of PUVs is credited to Langenbeck, who commented on valve-like folds in autopsy specimens, but did not infer any clinical significance. 1870. First comprehensive discussion of valves was raised by Tolmatschew. First to recognize this as a pathological entity and propose a theory as to its embryology. 1919. Finally, Young et al reported their series of 12 patients with PUVs, describing the clinical course, treatment and autopsy findings. In this study Young et al also created a classification system for valves, which remains the most commonly used system even today.
  13. 13. Introduction Definition: Posterior Urethral Valves are mucosal folds at the distal prostatic urethra that cause varying degrees of obstruction. • Most common cause of obstruction of bladder outflow in male neonates and infants. • Most common cause of Renal Replacement Therapy in Paediatric group in UK
  14. 14. Epidemiology • PUV affects exclusively in male infants • Occurs in about 1 : 8,000 births • Elevated incidence in African-Americans and children with Down’s syndrome • 10% of cases of prenatally diagnosed hydronephrosis overall
  15. 15. Normal anatomy of urethra
  16. 16. Young Classification Type I valves (95%) – Represents sail-like folds from the verumontanum distally along the urethra – They are thought to arise owing to the mesonephric ducts inserting abnormally into the cloaca.
  17. 17. Young Classification Type II valves – Extend proximally from the verumontanum to the bladder neck. – Likely have only historical significance and are not considered to be a clinical entity, but rather hypertrophied urethral folds
  18. 18. Young Classification Type III valve (5%) – Circular diaphragm distal to the verumontanum at the level of the membranous urethra. – Represent a cannulated septum thought by some to represent an incomplete dissolution of the urogenital membrane
  19. 19. Presentation Variable & Age dependent • Prenatally : 70% of PUV by Ultrasound • Newborns: Abdominal mass Ascites Respiratory distress Urosepsis Delayed voiding or poor stream • Infants: Urinary dribbling Enuresis Failure to thrive/ renal failure Urosepsis • Toddlers: UTI, Voiding dysfunction • School-age boys: Urinary incontinence
  20. 20. Pathophysiology Embryological defect causing Lower Urinary Tract Obstruction (LUTO) Oligohydramnios Increased vesical pressure Pulmonary hypolasia VUR Hydroureteronephrosis Renal Aplasia Urosepsis, Respiratory Failure ESRD Mortality
  21. 21. Diagnosis • Most commonly made by screening antenatal USG • Neonatal physical exam may demonstrate a palpable hypertrophied bladder • In severe cases, electrolyte abnormalities may lead to seizures or cardiac arrhythmias. • Older children may present with incontinence, vague abdominal complaints, UTI, distended bladder, thin urinary stream, or hematuria.
  22. 22. Investigations UltraSound is usually the first diagnostic tool – bilateral hydroureteronephrosis – a large, thick-walled bladder in severe cases. IVU can demonstrate the same. MCUG is the most diagnostic examination – will show a heavily trabeculated bladder – prominence of the bladder neck – dilatation of the posterior urethra – focal narrowing of the stream at the site of the valves – Vesicoureteral reflux should be sought Intraoperatively, endoscopy will visualize the valves if flow from the bladder is induced by suprapubic pressure
  23. 23. Postnatal Management Includes: • Stabilization of the patient • Drainage of the urinary tract • Correction of electrolyte abnormalities, particularly hyperkalemia • Intervention to treat respiratory distress, and urosepsis
  24. 24. Postnatal Management Drainage of Urinary Bladder 1. Placement of a catheter in the bladder • Temporary • Until patient stabilized • 8 F feeding tube over Foley’s catheter for better drainage
  25. 25. Postnatal Management Drainage of Urinary Bladder 2. Primary ablation during cystoscopy • Preferred initial surgical treatment • Ability to perform this procedure is determined by the size of the male urethra to accommodate the neonatal cystoscope. • Timing of this procedure is dependent on the overall health status of the neonate and issues with GA.
  26. 26. Postnatal Management Drainage of Urinary Bladder 3. Vesicostomy • performed in infants in whom safe visualization or ablation of the valves is not possible • relieves back pressure • is a reversible procedure • allows for the normal cyclical filling and emptying of the bladder at low vesical pressure
  27. 27. Postnatal Management Drainage of Urinary Bladder 4. Higher diversions • Cutaneous ureterostomies and pyelostomies are rarely indicated • Do not improve outcomes compared to vesicostomy • Commits a patient to subsequent major upper tract reconstruction • Higher diversions disrupt the filling and emptying of the bladder, which may further impact on bladder function.
  28. 28. Post-procedure Management Starts after a successful procedure that relieves or bypasses the intervention 1. Detecting and treating bladder dysfunction  Evaluated by imaging and urodynamic studies.  Clean Intermittent Catheterization & Anticholinergic medications • lowers bladder pressures in patients with severe bladder dysfunction (ie, low capacity, poorly compliant bladders with high filling pressure). • may reduce the rate of vesico-ureteral reflux, if present post-ablation 2. Monitoring renal function 3. Managing the consequences of CKD.
  29. 29. Outcome Despite prenatal diagnosis and early intervention, a significant number of patients will develop  ESRD  Persistent bladder dysfunction • Detrusor hyper-reflexia (29%) • Hypertonic and poor compliant bladder (31%) • Myogenic failure and overflow incontinence (40%)  Reflux is present in 48% to 70% of PUV patients  Persistent Hydronephrosis/Hydroureteronephrosis High-pressure reflux during the prenatal period may lead to  Renal dysplasia
  30. 30. Follow-up MCUG at 2 months after treatment to ensure destruction of valves Regular USG to evaluate resolution of HDN Ongoing monitoring of renal function is important • In order to anticipate associated CKD • Medical conditions that may require intervention • To provide counseling to patients at risk for ESRD and their families regarding options for renal replacement therapy
  31. 31. Prognosis • Late Presentation, Cr > 1.0 after 1 month of treatment, Type III PUV all have worse prognosis • 30 % cases develop some long term kidney failure • If associated with oligohydramnios and pulmonary hypoplasia 50% mortality. • Postnatal vesicoureteral reflux is present in one-third to one- half of patients worse prognosis but one third of these cases resolve spontaneously after valve ablation
  32. 32. Conclusion • Type I is the most commonest. • USG and MCUG are the modalities of diagnosis • Drainage, Antibiotics and correction of metabolic disturbances is the initial treatment • Majority are managed by valve ablation • Basically 2 types of PUV, Type III being with worse prognosis • Long term sequel significant, regular F/U necessary to diagnose early Renal Disease.
  33. 33. Journal
  34. 34. Ureteropelvic Junction Obstruction
  35. 35. Definition • A ureteropelvic junction (UPJ) obstruction can be considered a restriction to flow of urine from the renal pelvis to the ureter, which if left uncorrected, will lead to progressive renal deterioration.
  36. 36. Epidemiology • UPJ obstruction is the most common cause of significant dilation of the collecting system in the fetal kidney (48%) • Estimated at 1 in 5,000 live births. • More commonly in boys than in girls. • Especially in the newborn period, where the ratio exceeds 2 : 1 • Left-sided lesions pre- dominate, particularly in the neonate (approximately 67%). Bilateral UPJ obstruction in 10% to 40% of cases. • Noted in 21% of children with the VATER (Vertebral defects, imperforate Anus, Tracheoesophageal fistula, and Radial and Renal dysplasia) association.
  37. 37. Etiology • Intrinsic: Narrowed, dysfunctional or adynamic segments. • Extrinsic: Upper ureter is angulated, kinked or compressed by bands or adhesions.
  38. 38. Intrinsic obstruction • Mechanical: narrowed → incomplete embryological ureteric bud recanalization; muscular invaginations overdevelop as flaps or valves. • Functional: adynamic or dysfunctional segment → inability to initiate or conduct peristaltic waves across the UPJ. Figure: Intrinsic narrowing of upper ureter contributing to ureteropelvic junction obstruction.
  39. 39. Extrinsic obstruction • Vessel or fibrous band may pass anterior to the pelvis & ureter: most common. • May secondary to intrinsic disturbance which produces pelvic over distension & rotation. • High insertion of the ureter into the pelvis. Figure: A lower pole–crossing vessel contributes to significant kinking at the ureteropelvic junction and resultant intermittent obstruction. Often, when the ureter is mobilized, no evidence of intrinsic narrowing is found. Insertional anomaly and peripelvic fibrosis may also be present as secondary obstructive factors.
  40. 40. Symptoms & Signs • Asymptomatic • Insidious onset of pain • Sensation of draggaing heavyness that worsen by excessive fluid intake. • Enlarged kidney may be palpable. • Attacks of acute real colic may occur with no palpable swelling. • Symptoms of UTI and/or pyelonephritis . • Post strain hematuria. 1. Bernstein et al, 1988 ; Wolpert et al, 1989
  41. 41. Diagnosis • Prenatal Ultrasound • Excretion urography • CT scan • MR urography • Isotope renography : A)DTPA(Diethylenetriamine penta-acetic acid) B)MAG-3 • Whitaker test • Retrograde pyelography
  42. 42. Figure: These neonatal ultrasound images come from infants with a history of prenatally detected renal dilation. (A) This ultrasound is normal for comparison purposes. There are dark renal pyramids (arrow) and no renal pelvic dilation. (B) This image shows isolated renal pelvic dilation (arrow) (SFU grade I). (C) This image shows dilation of the renal pelvis (solid arrow) and upper and lower-pole calyces (dotted arrows) (SFU grade II). (D) Calyceal dilation and cortical thinning are seen (SFU grade IV). (E) Hydronephrosis with peripheral cysts (arrow) indicating dysplasia is seen. This kidney had no function on renal scan. The Society for Fetal Urology (SFU) classification is used to describe the degree of dilation.
  43. 43. Management • Medical Mx: Focused on a) Maintaining sterile urine. b) Assessing renal function and the degree of hydronephrosis. c) Intervention (Double J stenting) is indicated in infants and children if clearance half –time (T1/2) >20min, differential function <40% and ongoing parenchymal thinning with or without contralateral hypertrophy. Intervention is also indicated in those with pain, hypertension, hematuria, secondary renal calculi, and recurrent urinary tract infections.
  44. 44. Management (Continued…) • Surgica Mx: Principles are: • Formation of a funnel • Dependent drainage • Watertight anastomosis • Tension-free anastomosis Either open or laparoscopic pyeloplasty is gold standard for the treatment of PUJ obstruction. In children, the procedure of choice is an Anderson-Hynes dismembered pyeloplasty.
  45. 45. Vesicoureteric reflux
  46. 46. Vesicoureteric reflux • VUR refers to the retrograde passage of urine from the bladder into the ureter.  38% of children with prenatal hydronephrosis .  May presence normal postnatal ultrasound .  Reflux may be present in up to 70% of infants who present with UTI.
  47. 47. • Primary Vesicoureteric Reflux: Main reason for it is a fundamental deficiency in the function of the UVJ antireflux mechanism while remaining factors (bladder and ureter) remain normal or relatively noncontributory. • Secondary Vesicoureteric Reflux: Reflux caused by overwhelming the normal function of the UVJ. Bladder dysfunction of a congenital, acquired, or behavioural nature is often the root cause of secondary reflux.
  48. 48. Figure: Components of the competent ureterovesical junction. Those abnormalities most often implicated in the etiology of vesicoureteral refux are outlined. BOO, bladder outlet obstruction; NVD, neurovesical dysfunction.
  49. 49. International Reflux Study in Children classification system  Grade I reflux into a non- dilated ureter.  Grade II reflux into the upper collecting system but non dilated.  Grade III reflux is present in a dilated ureter with possible blunting of calyceal fornices.  Grade IV reflux into a grossly dilated ureter  Grade V massive reflux with significant ureteral dilatation and tortuosity with loss of the papillary impressions.
  50. 50. Surgical Indications  Breakthrough UTI during antibiotic prophylaxis.  Anatomical abnormalities: – Periureteric bladder diverticulum. – With the ureter inserting in the diverticulum. – Grade IV & V in duplicated collecting system. – Ureteral ectopia inserting in bladder neck or urethra. – Ureterocele. – Bladder exstrophy. – Prune-belly syndrome.  Persistence in adolescence.  Grade V.  Noncompliance to medical treatment.  Ureteral obstruction.
  51. 51. Various operative options Subtrigonal injection Extravesical detrusorrhaphy Advancement - detrusor closure, urothelial closure, ureteral anastomosis • Hutch - detrusor closure, urothelial closure • Leadbetter-Politano - detrusor closure, urothelial closure, ureteralanastomosis • Paquin - urothelial closure, ureteral anastomosis • Ureteral reinplantation • Leadbetter-Politano • Cohen cross-trigonal Modified Lich-Gregoir
  52. 52. URETHRAL STRICTURE • Exclusively in males 1. Congenital 2. Infections – secondary to urethritis by catheter 3. Traumatic – non iatrogenic (20%) – iatrogenic (60%)
  53. 53. • Present with urinary retention • Diagnosis – suspected from history and PE • IVU, retrograde urethrography (helpful) • Endoscopy : direct visualization TREATMENT • Diversion (intubated or tubeless) • Manipulation (intubation, dilation) • Endoscopic urethrotomy (knife, electrical or laser) • Repair (excision & re-anastomosis, single staged / multi staged repair)
  54. 54. MEATAL STENOSIS • Usually as a result of previous episodes of meatitis by ammoniacal inflammation. • Associated with balanitis xerotica obliterans. • No endoscopy. • Treatment – ventral meatotomy. – diagnosis requires instrumental calibration or observation of voided stream.
  55. 55. PHIMOSIS • Inability to retract foreskin. • Neonate – physiologic due to natural adhesions between prepuce & the glans. • > 3yr – 90% retractable • at 17 yr - <1% phimosis • Secondary phimosis : early forceful retraction – recurrent adhesions & cicatrical preputial ring. • Tx. circumcision or dorsal slit. Figure: Conditions associated with the uncircumcised penis. A, Phimosis due to a preputial ring. B, Paraphimosis with associated entrapped prepuce behind the glans penis.
  56. 56. Some Important Investigation Plain Abdominal Radiography 1) as a primary study 2) as a scout film in anticipation of contrast media. Ultrasonography Ultrasonography is a versatile and relatively inexpensive imaging modality that has the unique feature of being the only imaging modality to provide real-time evaluation of urologic organs and structures without the need for ionizing radiation.
  57. 57. Micturating cystourethrogram 1. Evaluation of structural and functional bladder outlet obstruction 2. Evaluation of reflux 3. Evaluation of the urethra in males and females 4. Gold standard investigation for posterior urethral valve.
  58. 58. Retrograde urethrogram 1 Evaluation of ureteral stricture disease 2 Assessment for foreign bodies 3 Evaluation of penile or urethral penetrating trauma 4 Evaluation of traumatic gross hematuria
  59. 59. Intravenous urography • Demonstrate the renal collecting systems and ureters • Investigate the level of ureteral obstruction in renal units displaying delayed function • Demonstrate intraoperative opacification of collecting system during extracorporeal shock wave lithotripsy or per- cutaneous access to the collecting system • Demonstrate renal and ureteral anatomy in special circumstances (e.g., ptosis, after transureteroureterostomy, after urinary diversion)
  60. 60. Cystourethroscopy 1. Rigid 2. Flexible Indication • Cystourethroscopy is used to directly visualize the anterior urethra, posterior urethra, and the bladder. • Evaluation of voiding symptoms, surveillance of urothelial carcinoma, foreign body removal, and assisting in difficult placement of a catheter.
  61. 61. Thank You
  • edsazzy

    Feb. 3, 2021
  • PriyankaBhadikar

    Sep. 11, 2020
  • shahinurrahman28

    Oct. 23, 2018
  • HassanMajeed10

    Oct. 10, 2018
  • FayisaFikadu

    Feb. 4, 2018
  • OdeyemiOlamilekan

    Oct. 5, 2017
  • adebolabiala

    May. 25, 2017
  • nashwamawad

    Nov. 11, 2016

Brief descriptions about all categories of obstructive uropathies.

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