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EMMANUEL L. BARCENAS, M.D.

Urologist/Urologic Surgeon,
Urology Specialty Group and Associates
Doctor of Medicine, SWU
Residency in General Surgery and Urology, Vicente Sotto Memorial
Medical Center
Diplomate, Philippine Board of Surgery and Philippine Board of Urology
Professional Organizations:
Member, Cebu Medical Society/Philippine Medical Association
Fellow, Philippine Urological Association
Fellow, Philippine College of Surgeons
Member, Philippine EndoUrological Society
Member, Philippine Society of Urologic Oncology

OBSTRUCTIVE UROPATHY
Upper Urinary Tract Obstruction
Lower Urinary tract Obstruction

Definitions:
Hydronephrosis is the dilation of the renal pelvis or

calyces. It may be associated with obstruction but may


be present in the absence of obstruction eg UTI.
Obstructive uropathy refers to the functional or

anatomic obstruction of urinary flow at any level of the


urinary tract.
Obstructive nephropathy is present when the

obstruction causes functional or anatomic renal


damage.

Symptom
Pain secondary to stretching of the

urinary collecting system.


The pain produced by ureteral

obstruction is typically colicky in nature.


Hematuria in adults, should be regarded

as a symptom of urologic malignancy

Triphasic pattern of RBF and ureteral


pressure changes in UUO
With UUO, RBF increases during the first 1 to 2 hours
and is accompanied by a high hydraulic pressure of fluid
in the tubule (PT) and collecting system pressure
because of the obstruction.
In a 2nd phase lasting 3 to 4 hours, these pressure
parameters remain elevated but RBF begins to decline.
A 3rd phase beginning about 5 hours after obstruction is
characterized by a further decline in RBF, now paralleled
by a decrease in PT and collecting system pressure.

Changes with BUO or obstruction of a solitary kidney


are different.

There is a modest increase in RBF with BUO


that lasts approximately 90 minutes, followed
by a prolonged and profound decrease in RBF
Ureteral and tubular pressures are increased
for the first 4 to 5 hours, the ureteral pressure
remains elevated for at least 24 hours with
BUO

UUO vs BUO
With UUO, early renal vasodilation primarily

mediated by prostaglandins and NO is followed


by prolonged vasoconstriction and normalization
of intratubular-ureteral pressure as the
contralateral kidney contributes to fluid balance.
With BUO, little early vasodilation is seen, and

vasoconstriction is more profound.

Fibrosis after Obstruction


Urinary tract obstruction leads to progressive
and, permanent changes in the structure of the
kidney, including the development of
tubulointerstitial fibrosis, tubular atrophy and
apoptosis, and interstitial inflammation.
The events leading to fibrosis are thought to be
initiated by increased angiotensin II, other
profibrotic factors appear to play a significant

Renal Recovery after Obstruction


When acute, complete ureteral obstruction
is promptly relieved, full recovery of global
GFR can occur.
In the rat model, after 3 days of UUO, GFR,
and RBF were reduced to less than 10% of
their baseline values.
Both returned to their baseline within 14
days of relief of obstruction

Renal Recovery after Obstruction


Longer periods of complete ureteral obstruction
are associated with diminished return of GFR.
In dogs with complete UUO for 7 days, GFR 1
hour after relief of obstruction was 25% of the
preligation GFR.
Maximal recovery was 58% of baseline, and
this occurred within 57 days.

Clinical Implications:
Hallmark of partial or complete upper urinary

tract obstruction is hydroureteronephrosis (HN),


with the ureteral dilation extending to the level
of the obstruction
In the acute setting, the degree of HN does not

necessarily correlate with the degree of


obstruction, as it may take time for severe HN to
develop

Clinical Implications:
Serum creatinine may be elevated, but the
contralateral kidney will compensate so serum
chemistries may not indicate renal impairment
Partial obstruction may result in permanent loss of
function on the affected side if not alleviated
within several weeks.
Complete occlusion can cause permanent
dysfunction within 2 weeks

Diagnostic Imaging
Renal ultrasonography is a mainstay in the
evaluation of suspected urinary tract obstruction.
Renal parenchymal thickness can be measured
readily, and cortical thinning may be indicative of
chronic obstruction.
The renal pelvis and calyces can be imaged, and
dilatation is readily identifiable.

Diagnostic Imaging
Excretory Urogram
Acute urinary obstruction may be inferred from
the functional abnormality of a delayed
nephrogram and pyelogram on the affected side
or sides.
Delayed images may then ultimately reveal the
anatomic level of obstruction and perhaps
causation.

Diagnostic Imaging
Nuclear Renography
It provides a functional assessment without
exposure to iodinated contrast material.
The glomerular agent technetium (Tc) 99m
DTPA and the tubular agent 99mTc-MAG3
are most commonly used in the evaluation
of obstruction

Diagnostic Imaging
Unenhanced CT is the most sensitive
method of detecting urinary tract
stones and is currently the preferred
imaging modality for evaluating most
patients with suspected renal colic

Hypertension
Hypertension can be precipitated by ureteral
obstruction and is a well-recognized sequela of BUO
or obstruction of a solitary kidney.
Patients with BUO are typically volume overloaded.
Renin activation and resultant angiotensin II
generation have been demonstrated in animal
models of UUO and may be the mechanism by
which new-onset hypertension occurs in this setting

Renal Drainage
Minimally invasive endourologic and
interventional radiologic techniques allow
prompt drainage of the obstructed kidney.
DJ Stenting or Percutaneous Tube Nephrostomy
These measures may allow temporary drainage
until a definitive procedure is performed.

Post-Obstructive Diuresis
Following the relief of urinary tract obstruction,
a period of significant polyuria may ensue.
Urine outputs of 200 mL/hr or greater may be
encountered.
Mainly after relief of BUO or obstruction of a
solitary kidney
Mainly physiologic

Post-Obstructive Diuresis
Patients susceptible to this phenomenon typically
have signs of fluid overload including edema,
congestive heart failure, or hypertension
Subjects in whom BUO or UUO in a solitary kidney is
relieved should be monitored for a postobstructive
diuresis.
Serum electrolytes, magnesium, blood urea nitrogen
(BUN), and creatinine should be checked daily

Upper Urinary Tract


Obstruction

Urolithiasis
Ureteral Strictures
UPJ Obstruction
Gynecologic Malignancies
Bladder Cancer
Pregnancy

Urolithiasis

Key Points: Physicochemistry

Urine must be supersaturated for stones to


form.
Urinary calcium and oxalate are equal
contributors to urinary saturation of
calcium oxalate.
The noncrystalline component of stones is
matrix, which is composed of a
combination of mucoproteins, proteins,
carbohydrates, and urinary inhibitors.

Urolithiasis
Calculi are crystalline aggregates of one or more
components, most commonly calcium oxalate
Calcium phosphate, magnesium ammonium
phosphate (struvite), uric acid, or cystine
CT scans will demonstrate all calculi except those
composed of crystalline-excreted indinavir
Noncontrast CT scans have become the study of
choice to evaluate for urolithiasis.

Urolithiasis
Urinary calculi may occur anywhere in the urinary
tract.

Asymptomatic in the renal pelvis or bladder, but


they are a very common cause of symptomatic
ureteral obstruction.
Smaller stones (up to 6 mm) may cause severe
symptoms, such as flank pain and nausea, but
typically pass without intervention.
-Blockers, which relax the distal ureter,
may be given to reduce renal colic.

Urolithiasis
Calculi 7 mm are more likely to become

impacted or to have a prolonged passage


through the ureter
Intervention at the time of presentation is

preferred for larger stones (except in cases


where the calculus is in the very distal ureter)
due to the likelihood of repeat emergency room
visits for severe symptoms.

Urolithiasis
Obstructing stones often are temporized with
stent placement, which allows proximal collecting
system decompression.
When urinary infection coexists with an
obstructing stone, a stent can be placed, but a
PCN is preferable if the patient demonstrates any
instability

Urolithiasis
Definitive treatment of renal or
ureteral calculi (lithotripsy) is through
ureteroscopy, percutaneous
nephrostolithotomy (PCNL), or
extracorporeal shock wave lithotripsy
(ESWL)

Urolithiasis
Patients with recurrent stones will benefit
from examination of stone composition and
24-hour urine metabolic workup to
determine the underlying etiology.
Better hydration is useful for all etiologies
Most patients will benefit from alkalization
of the urine (e.g., potassium citrate)

Ureteral Strictures

Ureteral Strictures
Common etiologies of ureteral stricture
formation include ischemia, surgical and
nonsurgical trauma, periureteral fibrosis,
malignancy, or congenital.
Proper evaluation and treatment of a ureteral
stricture is essential to preserve renal function
and rule out the presence of malignancy.

Ureteral Strictures
An intravenous pyelogram, retrograde

pyelogram, or diagnostic ureteroscopy can


define the location and length of the
ureteral stricture reliably.
Ureteral stent placement is effective

acutely in treating most ureteral strictures,


in particular intrinsic ureteral strictures.

Ureteropelvic Junction
Obstruction

UPJ Obstruction
UPJ obstruction also is commonly observed in
children and young adults.
Intrinsic and extrinsic causes of UPJ obstruction
Intrinsic UPJ obstruction occurs in neonates due to
an adynamic or stenotic segment of proximal ureter.
Abnormal lower pole (i.e., accessory) renal arteries
may be a secondary cause of UPJ obstruction by
kinking the proximal ureter.

UPJ Obstruction
Nuclear scans (mercaptoacetyltriglycine

or 99mTc diethylene-triamine-pentaacetic acid) have replaced the IVP as


the diagnostic modality of choice.
Delayed clearance of contrast or

radiotracer implies obstruction.

UPJ Obstruction
Patients with infections or impaired
renal function require repair to
improve drainage.
Open dismembered pyeloplasty is
considered the gold standard
approach

Gynecologic Cancers

Gynecologic Cancers
In many forms of gynecological cancer, the malignant
disease itself may extend to involve the lower urinary
tract and complicate the overall plan of management.
It is difficult to offer definitive treatment as they
present in uremia due to associated obstructive
uropathy.
This is due to either external compression or
malignant involvement of lower ureters.

Gynecologic Cancers
Patients may be symptomatic or asymptomatic with

high blood urea nitrogen (BUN), serum creatinine and


electrolytes.
Urinary diversion by percutaneous nephrostomy (PCN)

is the commonly practiced method, not only to improve


renal function, but also to improve quality of life and
enable the patient to accept tumor specific palliative
treatment in most and curative treatment in some.

Bladder Cancer

Usually Unilateral
Tumor invading the ureteral orifice
Usually implies muscle invasive
tumor

Pregnancy

Pregnancy

Hydronephrosis develops commonly during


pregnancy, the reported occurrence varying
between 43% and 100%
Progesterone, has been hypothesized to promote
ureteral dilatation and subsequent development
of hydronephrosis .

The increased incidence and degree of


hydronephrosis after the 20th week of gestation,
a time when the uterus is large enough to
compress the ureters extrinsically, supports a
mechanical etiology

Pregnancy
The typical ultrasonographic findings of

this entity are hydroureteronephrosis


extending to the pelvic brim.
The majority of patients with symptomatic

hydronephrosis of pregnancy can be


managed with conservative measures.

Lower Urinary Tract


Obstruction

Lower Urinary Tract


Obstruction

Benign Prostatic Hyperplasia


Urethral Stricture

Benign Prostatic
Hyperplasia

Benign Prostatic
Hyperplasia
Benign prostatic
hyperplasia (BPH) is a
pathologic process that contributes to
lower urinary tract symptoms (LUTS) in
aging men.
Prostatic hyperplasia increases urethral

resistance, resulting in compensatory


changes in bladder function.

Benign Prostatic
Hyperplasia

Obstruction-induced changes in detrusor

function, compounded by age related changes in


both bladder and nervous system function, lead
to urinary frequency, urgency, and nocturia, the
most bothersome BPH-related complaints.
The size of the prostate does not correlate with

the degree of obstruction.

Benign Prostatic
Enlargement

The symptoms of BPE are urinary

frequency, urgency, hesitancy, slow


stream, and/or nocturia.
Over time, incomplete emptying may lead
to chronic bladder overdistension that can
result in a defunctionalized bladder.

Benign Prostatic
Enlargement
Medical treatment of BPH is usually the first
step.
-Blockers act on receptors in the smooth
muscle of the prostate and decrease its tone.
5-Reductase inhibitors, which block the
conversion of testosterone to the more potent
Z, shrink the prostate over several months.

Benign Prostatic
Enlargement
Transurethral
resection of the prostate is the
mainstay of endoscopic surgical BPH treatment.
When the prostate is very enlarged (>100 g),
open surgical procedures can be used.
Suprapubic (simple) prostatectomy involves
enucleation of the majority of the prostate, but
the capsule is left so there is minimal effect on
continence and erectile function.

Urethral Stricture

Urethral Stricture
Strictures may result from scarring due to infectious
urethritis, prior instrumentation, trauma, or cancer
Diagnosis is by retrograde urethrogram or cystoscopy.
They may be treated with dilation or transurethral incision,
but they have a tendency to recur after treatment.
Open surgical excision is preferred for long or recalcitrant
strictures, and long-term success rates are excellent

Urethral Stricture
Anterior urethral disease, or a scarring process
involving the spongy erectile tissue of the corpus
spongiosum (spongiofibrosis)
Posterior urethral stricture is an obliterative
process in the posterior urethra that has resulted
in fibrosis and is generally the effect of
distraction in that area caused by either trauma
or radical prostatectomy

A retrograde urethrogram shows a totally


obliterative process involving the proximal bulbous
urethra.

wide-caliber annular area proximal to the obliterative


process of the bulbous urethra

Dilation
Urethral dilation is the oldest and simplest
treatment of urethral stricture disease.
The goal of this treatment, is to stretch the scar
without producing more scarring.
The least traumatic method to stretch the urethra
is to use soft techniques over multiple treatment
sessions.

Internal Urethrotomy
Internal urethrotomy refers to any procedure that opens

the stricture by incising it transurethrally.


The urethrotomy procedure involves incision through

the scar to healthy tissue to allow the scar to expand


(release of scar contracture) and the lumen to heal
enlarged.
Many surgeons have learned to perform internal

urethrotomy by making a single incision at the 12oclock position.

Excision and
Reanastomosis
The most dependable technique of
anterior urethral reconstruction is the
complete excision of the area of
fibrosis, with a primary
reanastomosis of the normal ends of
the anterior urethra

Pelvic Fracture Urethral Injuries


Pelvic fracture urethral injuries are the result
of blunt pelvic trauma and accompany about
10% of pelvic fracture injuries.
In these patients, the placement of an
aligning catheter may allow the urethra to
heal virtually unscarred or with an easily
managed stenosis.

Pelvic Fracture Urethral Injuries


When the patient is successful in relaxing to

void and the cystogram outlines the posterior


urethra, a simultaneous retrograde urethrogram
nicely outlines the length of the injury defect.
Primary anastomosis is the goal in all these

patients until it is proved impossible to perform.

Pelvic Fracture Urethral Injuries

The classic reconstruction consists of


a spatulated anastomosis of the
proximal anterior urethra to the
apical prostatic urethra.

Common Surgeries of the


Male Genital Tract
November 7, 2016
10am to 12 nn