Muhammad Sajid Bin Mohd Rafee

112016389
dr Abraham Sp.U
 Evaluasi Obstruksi Saluran Atas
 Obstruksi uteropelvic
 Retrocaval ureter
 Kelainan striktur uretheral
 Uteroenteric anostomotic stricture
 Retroperitonal stricture
 Although most cases are congenital, the
problem may not become clinically apparent
until much later in life (Jacobs et al, 1979).
Acquired conditions such as stone disease,
postoperative or inflammatory stricture, or
urothelial neoplasm may also manifest
clinically with symptoms and signs of
obstruction at the level of the UPJ.
 Focus on congenital
patophysiology
 Congenital UPJO typically results from intrinsic
disease. A frequently found defect is the
presence of an aperistaltic segment of the
ureter.
▪ histopathologic studies reveal that the spiral musculature
normally present has been replaced by abnormal longitudinal
muscle bundles or fibrous tissue
 This results in failure to develop a normal
peristaltic wave for propagation of urine from
the renal pelvis to the ureter.
 Intrinsic obstruction at the UPJ
 kinks or valves produced by infoldings of the
ureteral mucosa and musculature
 In children, vesicoureteral reflux can lead to
 upper tract dilation with subsequent elongation,
 tortuosity, and kinking of the ureter.
 Diuretic renography is the first-line modality for
differentiating between UPJO and reflux.
 Other acquired causes of obstruction at the UPJ
include
 benign lesions such as fibroepithelial polyps urothelial
malignancy,
 stone disease,
 and postinflammatory or postoperative scarring or
ischemia.. For instance, fibroepithelial polyps can be
managed using retrograde ureteroscopy and holmium
laser excision
 Historically, the most common presentation
in neonates and infants was the finding of a
palpable flank mass.
 However, the current widespread use of
maternal prenatal ultrasonography has led to
a dramatic increase in the number of
asymptomatic newborns being diagnosed
with hydronephrosis, many of whom are
subsequently found to have UPJO
 In older children or adults, intermittent
abdominal or flank pain, at times associated
with nausea or vomiting, is a frequent
presenting symptom. Hematuria, either
spontaneous or associated with otherwise
relatively minor trauma, may also be an initial
symptom. Laboratory findings of
microhematuria, pyuria, or frank urinary tract
infection might also bring an otherwise
asymptomatic patient to the urologist. Rarely,
hypertension may be a presenting finding
 Classically, excretory urographic findings include
delay in function associated with a dilated
pelvicalyceal system.
 The patient should be well hydrated and the
study then performed after injection of contrast
 CT scan is usually obtained for any patient with
acute flank pain
 Moreover, contrast-enhanced CT scans provide
detailed anatomic and functional information to
aid in diagnosis of UPJO
 Both ultrasonography and CT scanning also have a role in
differentiating acquired causes of obstruction such as
radiolucent calculi or urothelial tumors.
 In neonates and infants, the diagnosis of UPJO has usually
been suggested either by routine performance of
maternal ultrasonography or by the finding of a flank
mass. In either setting, renal ultrasonography is usually
the first radiographic study performed. Ideally,
ultrasonography should be able to visualize dilation of the
collecting system to help differentiate UPJO from
multicystic kidney and determine the level of obstruction.
 UPJO and multicystic kidneys are distinguishable in the
majority of patients by ultrasound alone.
 Diuretic renography remains a commonly used
study for diagnosing both UPJ and ureteral
obstruction because it provides quantitative
data regarding differential renal function and
obstruction, even in hydronephrotic renal units.
Diuretic renography is noninvasive and readily
available in most medical centers. Ideally,
diuretic renography can be used to follow
patients for functional loss, most effectively
when a standard protocol is used.
 preferable to have a combination of anatomic
and functional studies, such as retrograde
pyelogram and diuretic renography, to best
plan therapy.
 Contemporary indications for intervention for
UPJO include the presence of symptoms
associated with the obstruction, impairment
of overall renal function

 When intervention is indicated, the procedure

of choice has historically been dismembered
pyeloplasty; however, less invasive
endourologic approaches have a role as an
alternative
Endourologic :
 reduced hospital stays and postoperative
recovery.

However, the success rate does not approach

that of open, laparoscopic, or robotic
pyeloplasty. Furthermore, whereas open,
laparoscopic, or robotic pyeloplasty can be
applied to almost any anatomic variation of
UPJO, consideration of any of the less
 Percutaneous endopyelotomy is appropriate when the UPJO is
associated with upper tract stone disease because the
= Simultaneous Percutaneous Endopyelotomy and
Nephrolithotomy.
 The main advantage of a ureteroscopic approach is that it allows
direct visualization of the UPJ and assurance of a properly situated,
full-thickness endopyelotomy incision without the need for
percutaneous access.
 Open surgey
 Laparoskopi
 Retrocaval ureter is a rare congenital urologic
anomaly. It occurs as a consequence of the
persistence of the posterior cardinal veins
during embryologic development > inferior
vena cava
 Finding characteristic S-shaped deformity on
intravenous or retrograde pyelography
 The standard repair of retrocaval ureter is
open surgical pyelopyelostomy. In this
procedure, the ureter, dilated renal pelvis,
and inferior vena cava are identified and
dissected using the standard open surgical
techniques. The dilated renal pelvis is then
transected, then the ureter is transposed to
its normal anatomic position anterior to the
vena cava
 Common causes of ureteral stricture
formation include ischemia, surgical and
nonsurgical trauma, periureteral fibrosis,
malignancy, and congenital factors
 The presence of obstruction on standard CT
can identify ureteral stricture disease, but
antegrade or retrograde pyelogram, CT
urography, or diagnostic ureteroscopy is
necessary to define the location and length of
the ureteral stricture.
 Ureteral Stent Placement
 Balloon Dilation
 Retrograde Balloon Dilation.
 Antegrade Balloon Dilation.
 Endoureterotomy
 Retrograde Ureteroscopic Approach
 Antegrade Approach
 Combined Retrograde and Antegrade Approach
TECHNIQUE URETERAL DEFECT (cm)
 Ureteroureterostomy 2-3
 Open Approach
 Laparoscopic or Robotic Approach
 Ureteroneocystostomy 4-5
 Psoas hitch 6-10
 Boari flap 12-15
 Renal descensus 5-8
 Intubated Ureterotomy
 Open Transureteroureterostomy
 Laparoscopic Transureteroureterostomy
 Open Ileal Ureteral Substitution
 Laparoscopic Ileal Ureteral Substitution
Incidence and Etiology
 urinary diversion : temporary , permanent
 Factors potentially influencing outcome in this
population include the technique used for
ureteral dissection, the segment of bowel used
for the diversion, and the type of anastomosis
performed. Because ureteral ischemia is central
to the cause of ureteroenteric strictures, careful
attention to dissection is necessary to prevent
complications.
Penanganan
 Although the initial procedures involved
simple balloon dilation and stent placement,
unsatisfactory results led to incisional
techniques using electrocautery; more
recently, the laser was applied using both
fluoroscopic and direct endoscopic control.
 Endourologic management of ureteroenteric or
ureterocolic strictures, unlike the management of
ureteral strictures, still favors antegrade management.
Accordingly, endourologic procedures typically begin
with antegrade percutaneous access. Simple
percutaneous drainage is continued to allow relief of any
associated infection or obstruction-related renal
dysfunction. Once the patient’s condition is clinically
stable, fluoroscopic control is used to pass a guidewire in
an antegrade fashion across the anastomotic stricture,
over which a balloon catheter can be positioned and
inflated until the waist disappears. Stents are a routine
part of endourologic management, and these are typically
inserted in this same antegrade fashion