Upper Tract

Obstruction
Wahjoe Djatisoesanto
Dept. of Urology
Airlangga University Dr.Soetomo Hospital
01/23/16

CLASSIFICATION OF OBSTRUCTIVE UROPATHY

U.T.O
UPPER TRACT
ACUTE

LOWER TRACT

CHRONIC
UNEQUIVOCAL
EQUIVOCAL
NON FUCTION
INTERACTIVE

U.T.O.: Urinary Tract Obstruction

ACUTE OBSTRUCTION

ETIOLOGY

Stone
Sloughed renal papillae
Blood clot
Acute retroperitoneal pathology
Accidental ureteric ligation

01/23/16

ACUTE OBSTRUCTION
PATHOPHYSIOLOGY
Intrarenal pressure
Renal blood flow (RBF)
Glomerular filtration rate (GFR)
Tubular function
Obstructive atrophy
01/23/16

SYMPTOMS & SIGNS

Asymptomatic (incidental)
Symptoms:

Acute or chronic
Uni or bi-lateral
In or ex-trinsic
Complete or partial

Flank pain
Nausea, vomiting, fever, chilling, anuria

01/23/16

INTRA RENAL PRESSURE

Time

Coll.syst.pressure

RBF

Phase I

0 90 min.

Phase II

90 min 4 h

(remains elevated)

Phase III

4 18 h
(to resting)

01/23/16

(to below control)

(cont.decreased)

BIOMECHANICS OF URETERIC
OBSTRUCTION

Law of Laplace

relationship between intraluminal pressure, volume & tension in the

wall of a compliant homogeneous sphere under equilibrium
conditions
P..R = T.{.(R+e)-R}
Simplified:

P.R = T.(2.R.e.+e )

Assuming e is constant & that e << R, elimination of e yields:

P.R.= C.T
Or:

Tension X wall thickness

Pressure = -----------------------------Radius

01/23/16

P = intraluminal pressure
R = radius of the sphere
e = wall thickness
T = wall tension
= 22/7 or 3.14

UPPER TRACT OBSTRUCTION

INVESTIGATION
1. IVP
2. USG
3. RADIONUCLIDE (RENOGRAM)
4. CT

01/23/16

UPPER TRACT OBSTRUCTION

01/23/16

UPPER TRACT OBSTRUCTION

INVESTIGATION
1. IVP
2. USG
3. RADIONUCLIDE (RENOGRAM)
4. CT

01/23/16

UPPER TRACT OBSTRUCTION

01/23/16

UPPER TRACT OBSTRUCTION

INVESTIGATION
1. IVP
2. USG
3. RADIONUCLIDE (RENOGRAM)
4. CT

01/23/16

Figure : The effect of obstruction on the renogram curve. A, mild obstruction;

b, moderate obstruction;c, high-grade obstruction.

UNEQUIVOCAL CHRONIC OBSTRUCTION

Pathophysiology

Obstruction high i.r.press. fall (N range)

RBF declines pre obst.level after 3-4 h declining to

the new, reduced level

GFR falls progressive

Tubular function affected hypotonic

Urinary osmolality & Na content increased

01/23/16

UNEQUIVOCAL CHRONIC OBSTRUCTION

Primary mega ureter
Retrocaval ureter
Retroperitoneal fibrosis
Urothelial tumor
Ureteric stone
Ureteric stricture
Congenital
Tuberculosis
Bilharzial
Iatrogenic
Radiation
Retroiliac ureter

01/23/16

Ovarian vein syndrome

Endometriosis
Extrinsic obstruction
Bowel malignancies (e.g. colon)
Pelvic malignancies (e.g.cervix)
Pregnancy
Ureterocele
Bladder cancer
Malacoplakia
BPH
Prostate Ca
Procidentia
Pelvic lipomatosis
Urethral stricture
Phimosis

EQUIVOCAL CHRONIC OBSTRUCTION

UPJ stenosis
Primary megaureter
VUJ stenosis
Urinary diversion
Apparent ureteric stricture
Pregnancy
Infective dilatation
Duplication

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Previous surgery:
ureterolithotomy
re-implantation
pyelopasty
Previous endourology:
ureteroscopy
basketry

UPPER TRACT OBSTRUCTION

Indications of emergency drainage
Types of urinary drainage
Considerations in:
type of the procedure
timing

Case presentation
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UPPER TRACT OBSTRUCTION

Types of emergency drainage
External:
Nephrostomy
Open
Percutaneous (PNS)

Internal
Double-J stenting

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UPPER TRACT OBSTRUCTION

Considerations in:
type of the procedure
Degree of dilatation
Patient condition --- positioning
Local or general/regional anesthesia
Drainage only or definitive treatment

timing
01/23/16

UPPER TRACT OBSTRUCTION

Indications of emergency drainage

Obstructive anuria
Urosepsis caused by
Pyonephrosis
Infected Hydronephrosis

01/23/16

CONCLUSION
Upper Tract Obstruction may be acute or
chronic, uni or bilateral, unequivocal or
equivocal
Unequivocal diagnosed by imaging technique
Equivocal obstruction requires functional and
urodynamic assessment
Emergency drainage is indicated when there
are obstructive anuria and pyonephrosis
Hemodialysis is needed if indicated and should
be discussed appropriately
01/23/16