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OBSTRUCTIVE UROPATHY Introduction: Obstructive uropathy is a common urological problem.

It can occur anywhere along the urinary tract from the kidneys to the urethral meatus. Interruption of urinary flow results in pain, infection, sepsis, and loss of renal function. Therefore, the detection of obstruction, regardless of presentation, warrants early relief. Clinical Presentation: Acute Chronic In acute obstruction, eg. by ureteric stone, increased pressure and distention proximal to the point of obstruction causes pain. In chronic obstruction, eg. in BPH, the obstructive process is slow and progressive and without significant clinical symptoms. However, prolonged pressure and distention of the bladder results in structural distension, with subsequent loss of detrusor function. When this bladder pressure is not relieved, back-pressure changes result in hydronephrosis and permanent renal damage may ensue. Infection can develop in an environment of prolonged urinary stasis. Any obstruction with concomitant infection requires immediate intervention because urosepsis can lead to a life-threatening situation. Pathophysiology: Bladder:In long-term infravesical obstruction on the bladder, trabeculation and saccule formation in the bladder wall develop secondary to hypertrophied muscle. Later, mucosal diverticula, and, ultimately, detrusor muscle decompensation occurs. Urinary stasis secondary to inadequate bladder emptying results, thereby increasing the risk of infection, stone formation, and hydronephrosis. Ureter:Progressive back pressure on the ureter and kidneys results in hydroureteronephrosis. Hypertrophy of ureteral musculature results because of increased ureteral peristaltic activity. Ultimately, elongation and tortuosity of the ureter occur. Kidney:The increased intrarenal pressure leads to a decline in renal blood flow with progressive ischemia, compression of the papillae with decreased glomerular filtration, and thinning of the parenchyma due to loss of nephrons. Significant cortical atrophy will result in functional renal impairment. Aetiology: Urinary tract obstruction can be classified according to cause (ie, congenital versus acquired), duration (ie, acute versus chronic), degree (ie, partial versus complete), and level (ie, upper versus lower urinary tract). Location (ie, infravesical, ureteral, renal [UPJ]).

Also according to functional or mechanical causes. Mechanical causes are more common and the 3 main groups are: 1. Anatomical abnormalities, 2. Stones , 3. Tumours. Obstruction in children is associated most commonly with congenital anomalies such as ureteropelvic junction (UPJ) obstruction, ureterovesical junction (UVJ) obstruction (eg, ectopic ureter, ureterocele), or urethral valves (eg, posterior urethral valves [PUV]). In men, the most frequent causes of obstruction are prostate disease (eg, benign prostatic hyperplasia [BPH], cancer), stones, and urethral stricture. In women, obstructive problems are more likely to occur at a younger age secondary to pregnancy, stones, or pelvic malignancies (eg, ovarian, uterine, cervical). a) infravesical: Bladder outlet obstruction (BOO) are mostly secondary to mechanical causes, which include BPH, bladder neck contracture, urethral stricture, urethral valves, urethral stones, and foreign bodies. Functional bladder outlet obstruction is associated with neurogenic bladders, detrusor sphincter dyssynergia (DSD), and iatrogenic medical intervention (eg, anticholinergics). b) ureteral:Causes of ureteral obstruction generally are divided into processes. Intrinsic ureteral obstruction most commonly is due to stones, tumours (eg, urothelial), or strictures (eg, radiation, previous instrumentation). Obstruction secondary to extrinsic ureteral compression has been associated with pregnancy, tumors, retroperitoneal fibrosis (RPF), retrocaval ureter, and iatrogenic ligature. c) renal:Renal obstruction can be due to stones, tumour, UPJ obstruction, adynamic ureteral segment, or a crossing blood vessel. Clinical Presentation: Dependent upon the location of obstruction as well as the nature of the onset of obstruction. The principal symptom of upper tract obstruction is flank pain on the side of obstruction, often radiating along the course of the ureter down into the ipsilateral groin. When severe, this can be accompanied by GI symptoms (eg, nausea, vomiting). Concomitant infection is associated with fever, chills, dysuria, and cloudy urine. Haematuria suggests urinary stones, malignancy, or infection. Uremia associated with bilateral obstruction or obstruction of a solitary kidney can result in weakness, pallor, weight loss, peripheral oedema, and drowsiness. Lower tract obstruction is associated with voiding difficulties (eg, hesitancy, slow stream, straining to void, postvoid dribbling, sensation of inadequate emptying, double-voiding). Frequency, urgency and nocturia also develop because of inadequate bladder emptying. Suprapubic fullness or pain indicates impending acute urinary retention. Dysuria and cloudy urine suggest infection. On physical examination, the finding of an enlarged kidney is secondary to

significant hydronephrosis (especially in children). Secondary infection is associated with positive renal punch and fever. In lower tract obstruction, a palpable bladder indicates chronic urinary retention. Digital rectal examination usually reveals prostate enlargement. A decreased anal tone suggest damage to sacral nerve roots with resulting detrusor weakness (eg. cauda equine syndrome). Examination of the penis may reveal meatal stenosis. In women, a large cystocoele may be seen on pelvic examination. Lab Studies: Urinalysis (MCS). Pyuria, or WBCs in the urine, suggests the presence of inflammation and/or infection. The presence of nitrites and leukocyte esterase further indicates an infectious process, as does the finding of bacteria on microscopic examination. Suspicious urine should be sent for culture analysis for definitive microbial identification and specific antibiotic susceptibility. Haematuria suggests infection, stone or tumour. If a tumour is suspected, urine cytology may be helpful. Serum electrolytes Renal insufficiency (raised Urea /Cr) occurs if there is bilateral renal obstruction.In acute renal insufficiency, hyperkalemia and acidosis may be present. Complete blood count Leukocytosis (especially neutrophilia) indicates systemic infection. Anaemia is associated with chronic disease (eg, malignancy, chronic renal insufficiency). Imaging Studies: Intravenous urogram (IVU):In the patient with normal renal function (Cr <200), this is the study of choice for visualisation of the complete urinary tract because it provides both anatomical and functional information.Obstruction is characterised by delayed calyceal filling, delayed excretion of contrast, a prolonged nephrogram, and structural dilation proximal to the point of obstruction. Retrograde urethrogram:This contrast study is used to visualise the entire length of the urethra where urethral strictures and valves are suspected. Radionuclide studies:Assesses the differential functional capabilities of the kidneys.This modality is used to assess renal blood flow, parenchymal concentrating ability, and urinary

excretion and drainage. Delayed excretion following the administration of lasix suggests an obstructive process. Computed tomography (CT) scan:Any extrinsic compression along the urinary tract, retroperitoneal or pelvic tumours are readily visible on CT scan. Noncontrast spiral CT scan provides detailed structural information when diagnosing obstructing calculi, even radiolucent calculi (eg, uric acid, cystine stones);used to identify or rule out other intra-abdominal processes as the source of the presenting symptom (eg, appendicitis, cholecystitis, diverticulitis, abdominal aneurysms). Magnetic resonance imaging (MRI):The anatomical advantage of MRI over CT scan is in the ability to delineate specific tissue planes for surgical planning. In the general evaluation of urinary tract obstruction, the role of MRI is limited because it is costly. Diagnostic Procedures: CystoscopyAllows direct visualisation of the entire urethra and bladder and may reveal the obstructive process (eg, urethral stricture, prostatic hypertrophy, bladder neck contracture, ureterocoele).Bladder trabeculation and diverticula imply secondary effects of long-standing infravesical obstruction.Nowadays, the use of a flexible cystoscope in the clinic is a well tolerated, quick way to directly assess the LUT with the advantage that it can be done under LA. MX. In dog studies, renal impairment began after just 18-24 hours of complete obstruction. Continued complete obstruction for 1-2 weeks results in some irreversible deterioration of renal function, while complete obstruction for 16 weeks is associated with minimal reversal of renal impairment. If necessary, a temporary drainage device (eg, Foley catheter, ureteral stent, percutaneous nephrostomy tube) should be used to decompress the urinary system until full evaluation. Recovery of function is dependent upon the degree and duration of obstruction. Obstruction coexisting with infection is also a urological emergency and requires immediate relief with a Foley catheter, ureteral stent, or percutaneous nephrostomy tube. Broad-spectrum antibiotics are required. With the proximal pressure increases associated with obstruction, movement of the infected urine from the renal collecting system into the vasculature occurs, resulting in life-threatening urosepsis.Partial obstruction in the absence of infection can be managed initially with analgesics and prophylacticAbxs whilst awaiting Mx. Discomfort associated with obstruction is managed best with opioid analgesics, such as pethidine and NSAIDS. Indications for expeditious intervention and/or hospitalisation of a patient with hydronephrosis include complete obstruction;

obstruction in a solitary kidney; associated infection (fever, leucocytosis, bacteriuria), renal failure; uncontrolled colic and/or pain. When the point of obstruction is in the LUT (ie, urethra, bladder), decompression is accomplished by: Urethral catheter: the oldest, and remains the most frequent, retrograde manipulation performed on the urinary tract. In chronic urinary retention, clean intermittent catheterization (CIC) may provide an alternative to a long-term indwelling catheter. Suprapubic catheter: This is done if difficult urethral catheterisation is encountered eg. enlarged prostate, bladder neck contracture, or urethral stricture. A catheter is placed through the lower anterior abdominal wall (just superior to the pubis) and aimed directly into the bladder. Nowadays, this is done percutaneously at the bedside under local anesthesia. Ultrasound guidance is advised for percutaneous suprapubic tube placement in patients with prior abdominal or pelvic surgery or if the bladder is not full as there is a risk of potential bowel injury. Decompression of the UUT (kidney, ureter) is accomplished by Ureteral stent: Self-retaining flexible stents commonly known as double-J stents. This small tube has holes throughout and runs the length of the ureter from the renal pelvis to the bladder. It is placed endoscopically in the OT under fluoroscopic guidance. Percutaneous nephrostomy (PCN): A small tube is placed through the flank and directly into the renal pelvis, by the interventional radiologist. Only LA is required but broad-spectrum parenteral Abxs always should be administered. Also, any bleeding diathesis or uncontrolled hypertension should be corrected before the procedure to minimize the risk of perirenal haematoma. Sx. Definitive surgical intervention is D/o the cause, type, and duration of obstruction. Renal : ESWL(electrohydraulic shock wave lithotripsy; extracorporeal shock wave lithotripsy) for small stones (<2 cm) or PCNL for stones > 2 cm UPJ obstruction : either endopyelotomy, laparoscopic or open pyeloplasty (eg. Anderson-Hynes pyeloplasty) Ureteric stone : ureteroscopic lasertripsy or ESWL for small stones, ureterolithotomy for stones > 2 cm Ureteric stricture : Excision and end-to-end anastomosis for upper ureter location, reimplantation for lower ureter location Bladder - BPH : Transurethral incision of prostate (TUIP) for small prostamegaly, TURP for large BPH, Open prostatectomy for prostamegaly >100 ml. Bladder stone : Endoscopic cystolitholapaxy(removal of bladder calculi by intravesical crushing and then irrigating to remove fragments.) or open cystolithotomy for large (> 3 cm) and

multiple stones Urethral stricture : endoscopic optical urethrotomy(surgical incision of a stricture of the urethra.) for short segment (< 1cm), urethroplasty for long or recurrent strictures After relief of long-standing obstruction, a physiologic diuresis is expected. This usually is a self-limiting process and can be managed conservatively with fluid and electrolyte replacement. Three distinct types of postobstructive diuresis exist. Urea diuresis is the most common. It is self-limiting, lasting 24-48 hours. Monitor fluid balance and electrolytes. Unless otherwise contraindicated, increased fluid intake should suffice. Sodium diuresis is the second most common postobstructive diuresis. It usually is self-limiting but has the potential for longer duration (>72 h). Monitor fluid balance and electrolytes more aggressively (ie, intake and output [I/O], central venous pressure [CVP], urine and serum electrolytes). Replace fluids with isotonic sodium chloride solution 0.5 cc/1 cc urine as necessary. This is secondary to excretion of retained salt and water after relief of obstruction. Sometimes a pathological diuresis continues (after normalisation of volume status), requiring fluid and electrolyte replacement to avoid dehydration and hyponatremia. Water diuresis is rare and self-limiting, is a temporary nephrogenic diabetes insipidus, which occurs 2o to impaired renal tubular response to ADH. Prolonged bladder distention also can result in temporary impairment of detrusor function. After relief of obstruction, the urinary catheter should remain in place for several days to allow for recovery of detrusor function before attempting to remove the catheter. Follow-up: Obtain a final imaging study of the renal collecting system 4 to 6 weeks following complete relief of obstruction. IVU is the best study for this purpose. Further Reading:

Chen MY, Zagoria RJ, Dyer RB: Radiologic findings in acute urinary tract obstruction. J Emerg Med 1997 May-Jun; 15(3): 339-43[Medline]. Gulmi FA, Felsen D, Vaughan ED: The pathophysiology of urinary tract obstruction. In: Walsh PC, Retik AB, eds. Campbell's Urology. 7th ed. Philadephia, Pa: WB Saunders and Co; 1998: 342-385. Tanagho EA: Urinary obstruction and stasis. In: Tanagho EA, McAninch JW, eds. Smith's General Urology. New York, NY: McGraw-Hill; 1995: 172-185.

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