Downloaded 69 times
Uploaded byAhmed Ebrahim Helmy
Pujo
UPJ obstruction is a partial or complete blockage of urine flow from the renal pelvis to the ureter. It is often detected during prenatal ultrasound as hydronephrosis. Diagnosis is confirmed by diuretic renography showing delayed drainage. Conservative management involves monitoring with serial ultrasounds and antibiotics if VUR is present. Surgical intervention is considered if symptoms develop, renal function declines, or infections recur. Surgical options include open or laparoscopic pyeloplasty to reconnect the renal pelvis to ureter.
More Related Content
Pujo
- 1.
- 2. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 3. -The ureters arebilateral tubular structures responsible for transporting urine from the renal pelvis to the bladder . -They are generally 22 to 30 cm in length with a wall composed of multiple layers: -transitional epithelium -lamina propria -smooth muscle(inner longitudinal and outer circular) Adventitia.-
- 4. Sites of ureteral narrowing: -Ureteropelvicjunction. -Junction as the ureter crosses the iliac vessels. -Ureterovesical junction.
- 5. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 6. -Ureteropelvic junction (UPJ) obstructionis defined as a partial or complete obstruction of the flow of urine from the renal pelvis to the proximal ureter. -It can be congenital or acquired.
- 7. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 8. -- UPJ obstructionis present in 50% of patients diagnosed with antenatal hydronephrosis , occurring in 1 per 1000-2000 newborns. -The male-to-female ratio of is 3-4:1. -The left kidney is more commonly affected than the right kidney. - UPJ obstruction is less common in adults. - UPJ obstruction is bilateral in 10% of cases.
- 9. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 10. --The condition isfrequently encountered by both adult and pediatric urologists. - Congenital abnormalities may be observed in both adults and children, but adults may also present with UPJ obstruction secondary to surgery or other disorders that can cause inflammation of the upper urinary tract. - Usually caused by intrinsic stenosis of the proximal ureter, and less commonly by extrinsic compression of the UPJ.
- 11. Intrinsic narrowing - Inmost cases of UPJ obstruction, the upper segment of the ureter is narrowed or kinked, resulting in obstruction of urinary flow. -The underlying mechanism is not proven. -The most attractive theory is that the obstruction is secondary to muscular discontinuity, which disrupts the coordinated motion of smooth-muscle cells and may result in impeded peristalsis propagation across the UPJ and interference with urine bolus formation in the proximal ureter.
- 13. Extrinsic narrowing In about10 % of pediatric UPJ obstruction, an aberrant or accessory renal artery or arterial branch may cross the lower pole of the kidney, resulting in compression of the UPJ and blockage of urinary flow or secondary to surgery or other disorders that can cause inflammation of the upper urinary tract.
- 15. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 16. -The urinary drainagefrom renal pelvis to ureter is determined by many factors. Pressure within the renal pelvis is determined by the volume of urine produced, the internal diameter of the UPJ and collecting system, and the compliance of the renal pelvis, as well as the peristaltic activity of the ureter. - In response to the increased volume and pressure, the renal pelvis dilates. Initially, the smooth muscle of the renal pelvis may thin out, but over time, it may become hypertrophied to varying degrees.The effects on the developing renal parenchyma may be quite variable, owing to the compliance of the renal collecting system. Despite massive dilation, preservation of renal function may occur.
- 18. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 19. Intrauterine Widespread use ofantenatal ultrasonography and the advent of modern imaging techniques have resulted in earlier and more common diagnosis of hydronephrosis. Neonates Hydronephrosis
- 20. Older children - Urinarytract infection (UTI) - Flank mass - Intermittent flank pain secondary to a primary UPJ obstruction - Hematuria if it is associated with infection Adults - Back and flank pain correlates with periods of increased fluid intake ingestion of a food with diuretic properties - Urinary tract infection (UTI) - Pyelonephritis - Hypertension - Abdominal mass 30% diagnosed after UTI 25% diagnosed after hematuria
- 21. Associations 10%-Vesicoureteral reflux - imperferateanus - contralateral multicyctic kidney - congenital heart disease - esophageal atresia
- 22. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 23. -Infected hydronephrosis -Secondary stoneformation -Hematuria : Calcular or Malignant -Increase Succeptibility to trauma -Renal failure
- 24. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 25. Ultrasonography (US) Most cases ofUPJ obstruction present as a result of detecting hydronephrosis by prenatal ultrasonographic screening
- 26. Diuretic renography -It (renalscan and the administration of a diuretic) is used to diagnose urinary tract obstruction. It measures the drainage time from the renal pelvis (referred to as washout) and assesses total and each kidney's individual renal function. -The washout measurement correlates with the degree of obstruction. -In general, a half-life greater than 20 minutes to clear the isotope from kidney is considered indicative of the obstruction .
- 28. Computed tomographic scan(CT) - It is an alternative to ultrasonography in the symptomatic child. -It is not the preferred modality due to its radiation exposure. - In UPJ obstruction, the CT scan typically shows hydronephrosis without a dilated ureter.
- 30. Magnetic resonance imaging(MRI) - It can be used to diagnose UPJ type hydronephrosis. -The advantage of MRI is the ability to discern accurate anatomy defining the point of obstruction. -Also determine the split function of the kidney and simulate the diuretic renogram by providing washout data. -The disadvantage of MRI is the cost and the need for general anesthesia and/or sedation.
- 31. Voiding cystourethrogram (VCUG) -Itis performed in patients with hydronephrosis to confirm the presence or absence of VUR of both the affected and contralateral kidneys. -10% of patients with UPJ obstruction have contralateral low- grade vesicoureteral reflux. -Identification ofVUR is important because children with concurrent VUR and UPJ obstruction may be at higher risk for severe infection.
- 32.
- 33. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 34. To Breif -It isgenerally suspected when imaging studies, usually ultrasonography, demonstrate hydronephrosis. -The diagnosis is confirmed by diuretic renography. -30% diagnosed after UTI -25% diagnosed after hematuria -Complications
- 35. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 36. causes of hydronephrosis A)Obstructivecauses 1)PUJO 2)Ureteral Obstruction a-Lumen b-wall c-outside the ureter 3)Bladder 4)Urethra 5)Prostate B)VUR
- 37. Different renal swellings -Singleor multiple simple renal cysts -Multicystic kidney -Polysystic kidney -Renal tumors
- 39. - Remember! -- Definition -Epidemiology - Etiology -- pathophysiology -- Presentation - Complications -- Investigations -- Diagnosis -- Differential diagnosis - Management - References
- 40. Conservative -Follow up withUS and/or renal scan every 3- 4 months for 1 year and then every 4-6 months. -VCUG to assessVUR -Antibiotics ifVUR is present Principles -50% of antenatal hydro resolved postpartum . -observations that asymptomatic hydronephrosis can resolve spontaneously. -“Rule of 1/3” - 1/3 stay the same, 1/3 improve, 1/3 worsen.
- 41. Indications for SurgicalIntervention • Presence of symptoms associated with the obstruction. • Impairment of overall renal function. • Progressive impairment of ipsilateral function. • Development of stones or infection . • Hypertension.
- 42. Open Pyeloplasty – GoldStandard – Dismembered pyeloplasty is the most common
- 43. Foley V-Y-Pyeloplasty – Goodfor 1-2 cm obstruction – Best for high inserting ureter – Best with relatively small pelvis
- 44. Spiral flap pyeloplasty –Good for long obstructions (better in adults) – Length of flap limited only by size of pelvis • (keep length: width at 3:1) • good when UPJ angle > 90
- 45. Endopyelotomy – Antegrade orretrograde – Cold knife or electric current – Direct vision – 86% success in adults – Slightly less effective in children
- 46. Laparoscopic pyeloplasty – Sameindications as open or endourologic procedures – Dismembered pyeloplasty is most common procedure performed _Without crossing vessels, may do any number of flap procedures _ Up to 94% success rate, similar to open pyeloplasty
- 48.