Abdu Seminar on Ob Uropathynnnnnnn.pptx

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1. Seminar On Urinary Tract Obstruction (Obstructive Uropathy ) Presenter Dr Abdurazak (R3) Moderator Dr Tadele (Urologist ) 08-Dec-21 1

2. Outline Objective Introduction Prevalence Classification Causes Pathophysiology Hemodynamics Diagnosis Management Summary 08-Dec-21 2

3. Objective To define the spectrum upper UTO and outline its burden. Describe how to approach a patient with upper UTO. Discuss the management principles of common causes of upper UTO. 08-Dec-21 3

4. Introduction UTO is defined as an i nterruption of urine flow at some point from renal tubules to urethra . Increases pressure within urinary tract causing structural and physiologic changes. Can lead to mild and transient to permanent renal injury – Uropathy and /Or Nephropathy Can be as proximal as the calyces and as distal as the urethral meatus The degree of injury and overall renal function depends on 08-Dec-21 4

5. Prevalence Obstructive Uropathy accounts for 10% of all cases of renal failure. Obstruction of the urinary tract can occur at any age In children males are more affected than females age. Hydro nephrosis reported in 3.1% of individuals (autopsy series ). Hydro nephrosis common in women(20-60yr) and men (>60yrs) 08-Dec-21 5

6. Classification Congenital or Acquired A cute or Chronic C omplete or Partial Unilateral or Bilateral U pper or Lower Benign or Malignant 08-Dec-21 6

7. Causes 08-Dec-21 7

8. P athophysiology Effects of obstructive Uropathy depends on:- Degree of obstruction (partial or complete) Extent of obstruction (unilateral or bilateral) Chronicity (acute or chronic) Infection Presence of anomalies 08-Dec-21 8

9. Physiologic parameters that will be affected following obstruction:- Renal hemodynamics Glomerular filtration Tubular function Anatomic changes 08-Dec-21 9

10. Gross Pathologic Findings After 42 hours: The ureter and renal pelvis dilate Blunting of renal papilla Increase kidney weight due to edema At 7th day: Collecting system dilation, edema and renal weight further increase. At 12th day: Pelvi calyceal dilation increase further. At 21 to 28 days: The cortex and medullary tissue get diffusely thinned . 08-Dec-21 10

11. Microscopic Pathologic Findings At 42 hours: - Lymphatic dilation and interstitial edema. At 7th day: Duct and tubular dilatation will be prominent. Widening of Bowman space, Tubular basement membrane thickening. At 12th day: Papillary tip necrosis, Regional tubular destruction, Week 5-6 Widespread glomerular collapse and tubular atrophy , interstitial fibrosis , and proliferation of connective tissue in the collecting system 08-Dec-21 11

12. Hemodynamic Changes Different in unilateral and bilateral obstruction. Unilateral Ureteral Occlusion Has three phases:- Phase I: Occurs in the first 1-2 hours. RBF increases H igh PT and collecting system pressure because of the obstruction. Phase II: After 3 to 4 hours . Pressure parameters remain elevated B ut RBF begins to decline. Phase III: Begins about 5 hours after obstruction. I t is characterized by a further decline in RBF P aralleled by a decrease in PT and collecting system pressure 08-Dec-21 12

13. Bilateral Ureteral Occlusion Only modest increase in RBF. Lasts shorter (approximately 90 minutes) Prolonged and profound decrease in RBF. The ureteral pressure remains elevated for at least 24 hours. Glomerular filtration and RBF remain depressed after release of BUO 3 . Partial Ureteral Occlusion Renal hemodynamics and in tubular function occur slowly. Thus partial neonatal obstruction can impair nephrogenesis . 08-Dec-21 13

14. Hemodynamic and GFR Changes 08-Dec-21 14

15. Effects on Tubular Function Decreased urine concentrating ability and polyuria. Decreased Na+ ion reabsorption. Decreased K+ secretion in UUO but increased Secretion in BUO. Decreased urinary acidification. Other cations and anions:- Phosphate excretion is increased in BUO while retention in UUO. Magnesium excretion is markedly increased after the release of either UUO or BUO . 08-Dec-21 15

16. Approach - Diagnosis History Asymptomatic Symptoms: Variable depending on site, duration and degree of obstruction Flank pain Nausea or vomiting Hematuria Recurrent UTI Fever and Chills New-onset or poorly controlled hypertension Recent gynecologic or abdominal surgery Anuria Pain after increased fluid intake - flank pain after alcohol ingestion in unilateral PUJO or UVO 08-Dec-21 16

17. Physical Examination Blood pressure (hypertension ) Signs of dehydration and intravascular volume depletion Peripheral edema ,, signs of congestive heart failure. Palpable kidney or bladder Enlargement of pelvic organs ( eg . Prostate, uterus) Examination of external urethra for phimosis , meatal stenosis 08-Dec-21 17

18. Work Up Laboratory Studies Urinalysis Renal Function Test Fractional Excretion of Sodium Serum electrolyte 08-Dec-21 18

19. Diagnostic Imaging Ultrasound Important to make anatomic diagnosis: Renal size Cortical thickness Cortico medullary differentiation, Grade of collecting system dilation ( Hydronephrosis ) 08-Dec-21 19

20. Computed Tomography Gold standard for renal stone disease. Has a sensitivity of 96% and specificity of 100 %. Non contrast CT for patients presenting with acute flank pain Contrast-enhanced CT gives detailed anatomic and functional information. 08-Dec-21 20

21. Excretory Urography Provides both anatomic and functional information. Largely replaced by CTU . Should not be used in:- Patients with contrast allergy Renal insufficiency In pregnant women 08-Dec-21 21

22. Retrograde Pyelography/ Antegrade Pyelography Used for: asses exact site of obstruction Adequately define collecting system anatomy Patients with renal insufficiency or Patients who are un able to take i.v contrast If emergency decompression of UPJO is required If infection is present 08-Dec-21 22

23. Magnetic Resonance Urography Avoids radiation exposure. Gives both anatomic and functional information. Has 100% sensitivity in diagnosing upper UTO. The protocol involves: T1 and T2 weighted imaging with out contrast Then administering Godalinium based contrast 08-Dec-21 23

24. Nuclear Renography Provides non invasive information about dynamic renal function. Also known as diuretic renography /MAG3 scan. Differentiate obstructive vs. non obstructive hydronephrosis . Limited anatomic information 08-Dec-21 24

25. Treatment of Renal Obstruction General Measures – Acute Phase Treatment Pain management NSAIDs OPIOIDS calcium channel blockers Renal Drainage Percutaneous nephrostomy (PCN) Important in draining purulent content Allows urine output measurement Avoid ureteral manipulation Decrease risk of sepsis . Radiographic study Ureteral stenting Patient comfort Lower risk of bleeding 08-Dec-21 25

26. Temporary drainage procedures Complete obstruction , Unilateral vs Bilateral Obstruction with infection Obstruction with acute renal failure Obstruction in a Solitary native Kidney Obstruction in a renal allograft Obstruction in a Pregnant female ** Uncontrollable fever ,flank pain or gastro intestinal complaints, older , debilitated 08-Dec-21 26

27. Treatment of Renal Obstruction Definitive Management Depends on: The cause The function of affected kidney The status of contra lateral kidney Age of the patient Management of post obstructive diuresis . Treatment is commonly required:- For pathologic post obstructive diuresis. If there is altered mental status, electrolyte abnormality and signs of fluid overload Monitoring (V/S, serum e-, urine output and osmolality) Limit intravenous fluid ( 0.45% normal saline ) , 0.5 cc NS/1 cc Urine 08-Dec-21 27

28. Indications of Immediate Definitive Mx Partial obstruction by Stones Emphysematous pyelonephritis with obstruction - Nephrectomy 08-Dec-21 28

29. Common Causes Of Upper UTO Urolithiasis Ureteropelvic junction Obstruction. Ureteral stricture Retroperitoneal fibrosis Retrocaval Ureter 08-Dec-21 29

30. Ureteropelvic junction Obstruction (UPJO) Refers significant impairment of urinary transport from the renal pelvis to the ureter. Boys are more commonly affected girls Common on the left side and bilateral in 10% of cases. 08-Dec-21 30

31. Etiology of UPJO Congenital (intrinsic disease) Aperistaltic segment of the ureter Ureteral valves/kinks ureteral stricture “Aberrant” vessels Acquired Stone disease Post operative or inflammatory stricture Urothelial neoplasm Polyps 08-Dec-21 31

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33. Management of UPJO Indications for intervention Presence of symptoms associated with obstruction Impairment of overall or ipsilateral renal function Development of stone or infection Hypertension Goal of intervention: Relief symptoms Preserve or restore renal function. 08-Dec-21 33

34. Management Conservative Principles of conservative management Observation of asymptomatic hydronephrosis will resolve spontaneously. Patient needs careful observation with regular renal scan - Acute Management Surgical Intervention 08-Dec-21 34

35. Options for Intervention Open pyeloplasty Laparoscopic/robotic pyeloplasty Endoscopic pyeloplasty Nephrectomy Basic principles Reconstruct widely patent UPJ Provide water tight anastomosis Allow funnel shaped transition between the pelvis and ureter . 08-Dec-21 35

36. Dismembered Pyeloplasty/Anderson Hynes Pyeloplasty Advantage Can be used regardless of the site of ureteral insertion Allows reduction of redundant pelvis and straightening of tortuous ureter. Anterior and posterior transposition of the UPJ is possible. Excision of anatomically and functionally abnormal UPJ. Disadvantage Not suited for long or multiple proximal ureteral stricture. UPJ obstructions associated with small intra-renal pelvis. 08-Dec-21 36

37. Operative Technique Flank Approach : It is common and familiar for most urologists. Positioning Straight flank position Skin incision Flank incision Exposure Involves separation of three muscle/ fascial layers and opening transversalis fascia. 08-Dec-21 37

38. Operative Technique Identify the ureter and aberrant vessel (if any) The ureter is identified distal to the UPJ and cleaned of investing fat and fascia. Apply marking suture on the lateral aspect of the ureter below the narrowing 08-Dec-21 38

39. Operative Technique Ureteropelvic junction is excised. The lateral aspect of ureter is spatulated . Anastomosis the lateral part with inferior and the medial part with superior part of pelvis 08-Dec-21 39

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41. Reduction pyeloplasty Is performed when the renal pelvis is exceptionally redundant Excise redundant portion of the pelvis Close the cephalad portion of the renal pelvis down to the dependent part. Anastomose the dependent portion with the ureter 08-Dec-21 41

42. PUJ Transposition Is done for aberrant or accessory lower pole vessel. 08-Dec-21 42

43. Non-dismembered Reconstructive Procedures Mostly replaced by dismembered pyeloplasty Indicated in: High insertion of the ureter Long and more distal obstructions. Commonly performed non Anderson Hynes procedure include: Foley Y-V plasty Culp- DeWeerd Spiral Flap Scardino -Prince Vertical Flap 08-Dec-21 43

44. Foley Y-V plasty Indicated in UPJO secondary to high ureteral insertion. Contraindicated when there is crossing vessels and redundant renal pelvis. Operative technique Outline the flap with tissue marker or sutures Develop a V flap with its base directed to the dependent portion of the pelvis and bring the apex of the flap to the stem of Y incision. Approximate the posterior wall Complete the anastomosis by approximating anterior wall . 08-Dec-21 44

45. Culp- DeWeerd Spiral Flap Suited for large readily accessible extra renal pelvis and long segment narrowing . Operative technique Outline the spiral flap with the base directed obliquely on the dependent aspect. The flap is developed and medial line of incision is extended down. The apex is rotated down to the most inferior aspect of the ureterotomy . Anastomosis is done over an internal stent 08-Dec-21 45

46. Scardino -Prince Vertical Flap Used when dependent UPJ is situated at medial margin of large “box extra renal pelvis” 08-Dec-21 46

47. Laparoscopic pyeloplasty Has similar indication as open or endo urologic pyeloplasties . Comparable outcome with open pyeloplasty (94% success rate) Not suited for PUJ obstructions with crossing vessels. 08-Dec-21 47

48. Endo- pyelotomy Is less invasive procedure. It involves balloon dilation or incision with hot wire of narrowed UPJ. Not suited for PUJ obstructions with crossing vessels. Can be:- Anterograde pyelotomy or Retrograde pyelotomy Lower success rate (73%) Contraindications are:- Long segment obstruction Coagulopathy Active infection. 08-Dec-21 48

49. Ureteral Stricture Incidence in the general population is unknown. 08-Dec-21 49

50. Diagnostic Studies and Indications for Intervention Diagnostic studies: CT scan Antegrade and retrograde pyelogram CT urography /Diuretic renography Ureteroscopy and biopsy Indication for intervention Symptoms like pain Recurrent UTI Ongoing obstruction Need to rule out malignancy. 08-Dec-21 50

51. Options of Intervention Endoscopic intervention: Endoscopic stenting Balloon dilation Endoscopic ureterotomy Surgical repair 08-Dec-21 51

52. Endoscopic stenting Effective in acutely treating intrinsic stricture. Has a success rate of 88% in intrinsic obstruction. Eventual compression is common if it is used for external compression. Best suited for patients: With poor prognosis and Patients who are not candidate for surgical intervention. 08-Dec-21 52

53. Balloon Dilation Indicated in functionally significant obstruction. Contraindication for balloon dilation are: Presence of active infection Stricture segment longer than 2cm. It can be: Retrograde approach (initial intervention) Antegrade (done when retrograde approach fails) Ureteral stent is left in place for 2-4 weeks after initial dilation. 08-Dec-21 53

54. Endoureterotomy Endo luminal ureteral incision is a logical extension of balloon dilation. It is performed under direct vision using ureteroscopic control. Approach can be : Retrograde: preferred and is less invasive. Antegrade : is done if nephrostomy tube already exist. Combined method The site of ureteral incision depends on the location of the stricture: Anteromedial incision in lower ureteral stricture Lateral or posterolateral incision for proximal ureteral 08-Dec-21 54

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57. Ureteroureterostomy Indicated for short segment involving the upper and mid ureter. Incision depends on level of stricture (flank incision is commonly used) Tension free anastomosis to avoid stricture. Operative techniques Mobilize proximal and distal ureters Spatulate both ends (180* apart) Place a suture and E-to-E ureteroureterostomy Double J stent left for 4-6 wks 08-Dec-21 57

58. Ureteroneocystostomy It refers to reimplantation of the ureter into the bladder. Is appropriate for obstruction or injury in the distal 3-4cm of ureter . Approach:- Open Pfannenstiel or Lower midline incision.  laparoscopic Modification with Boari flap or Psoas hitch may be necessary. Ureteral stenting is typically required in open surgery. 08-Dec-21 58

59. PSOAS HITCH For t he lower third of the ureteral defect. Done when direct reimplantation not possible. Indications:- Distal ureteral stricture, injury Failed ureteroneocystostomy Contraindication:- Small bladder with limited mobility Urodynamic studies to estimate the bladder capacity is required. 08-Dec-21 59

60. The ipsilateral ureter is identified mobilized, and divided just above the diseased segment. Bladder is mobilized by freeing its peritoneal attachments. Anterior cystotomy created. 08-Dec-21 60

61. The ureter is delivered into the bladder and tension free anastomosis made. The ipsilateral bladder dome is secured to the psoas muscle. 08-Dec-21 61

62. Complications:- Persistent urine leak Uro -sepsis Ureteral obstruction Nerve injury, bowel injury, iliac vessel injury The success rate of uretero-neocystostomy with a psoas hitch is greater than 85%. 08-Dec-21 62

63. BOARI FLAP Preferred method when stricture is too long or limited ureteral mobility It can bridge a 10- to 15-cm ureteral defect, Conditions affecting bladder compliance should be treated first. Outcome is good if well vascularized flap is created. Commonest complication –recurrent stricture 08-Dec-21 63

64. Salvage Procedures RENAL DESCENSUS Involves mobilizing the kidney and rotating it inferiorly and medially. It used to bridge upper ureteral defects and to allow tension free anastomosis Lower pole secured to retroperitoneal muscles. Up to 8 cm of additional length may be gained. It can be combined with Boari flap in case of pan ureteral stricture. 08-Dec-21 64

65. Transureteroureterostomy Ureteral length is insufficient to reach bladder Contraindications: Absolute contraindications: In adequate donor ureter length Diseased recipient ureter Relative contraindications: Nephrolithiasis Retroperitoneal fibrosis Urothelial malignancy Chronic pyelonephritis , and Abdominopelvic radiation 08-Dec-21 65

66. Ileal - Ureteral Substitution Done only when other methods are not possible and bladder is not suitable for reconstruction. Proximal anastomosis could be at the level of renal pelvis or ileocalycostomy . Contraindicated: If baseline Cr>2mg/dl If there is bladder outlet obstruction Inflammatory bowel disease Radiation enteritis. Complications include Urine leak Urinoma Obstruction Metabolic Renal insufficiency 08-Dec-21 66

67. RETROPERITONEAL FIBROSIS Characterized by the presence of inflammatory and fibrous retroperitoneal tissue. True incidence is unknown. Commonly affects patients between the age 40 to 60. Male-to-female ratio 2:1 to 3 :1. It is idiopathic in 70% of cases. In around 30% of cases RPF is associated with: Drugs Malignancy Radiation Infectious causes 08-Dec-21 67

68. Diagnosis History Back or flank pain Other non specific symptoms Physical examination: Usually unremarkable Laboratory findings: Elevated WBC, ESR, CRP Renal insufficiency and electrolyte abnormality Imaging CT scan and CT urography Biopsy (rarely needed) 08-Dec-21 68

69. Management Initial management Decompression (PCN or ureteral stent) For patients with Hydronephrosis and uremia. Stop inciting drug (if any) Work up for the cause. Medical mangement Steroids Immunomodulators ( azathioprine , cyclophosphamide , cyclosporine, colchicine ) Surgical management Ureterolysis (open or laparoscopic) 08-Dec-21 69

70. Recovery GFR recovery After relieve Of UUO – 100 % after 7 days , 70 % after 14 days , 30 % after 4 weeks, No recovery after 6 weeks. 08-Dec-21 70

71. Summary High index of Suspicious is mandatory Through evaluation Imaging On Time Management Follow Up 08-Dec-21 71

72. References 08-Dec-21 72

73. Thank YOU 08-Dec-21 73