obstruksi upper tract
DESCRIPTION
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04/22/23
Urinary Tract Obstruction
Dr marzuki yusuf SpU
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CLASSIFICATION OF OBSTRUCTIVE UROPATHY
U.T.O
UPPER TRACT LOWER TRACT
ACUTE CHRONIC
UNEQUIVOCAL
INTERACTIVE
NON FUCTION
EQUIVOCAL
U.T.O.: Urinary Tract Obstruction
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ACUTE OBSTRUCTION
ETIOLOGY
• Stone• Sloughed renal papillae• Blood clot• Acute retroperitoneal pathology• Accidental ureteric ligation
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ACUTE OBSTRUCTION
PATHOPHYSIOLOGY
• Intrarenal pressure
• Renal blood flow (RBF)
• Glomerular filtration rate (GFR)
• Tubular function
• Obstructive atrophy
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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
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INTRA RENAL PRESSURE
Time Coll.syst.pressure RBF
Phase I 0 – 90 min. ↑↑ ↑↑
Phase II 90 min – 4 h ↔ ↓↓
(remains elevated) (to below control)
Phase III 4 – 18 h ↓↓ ↓↓ (to resting) (cont.decreased)
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BIOMECHANICS OF URETERIC OBSTRUCTION
Law of Laplacerelationship between intraluminal pressure, volume & tension in the wall of a compliant homogeneous sphere under equilibrium conditions
P.Л.R² = T.{Л.(R+e)²-R²} Simplified: P.R² = T.(2.R.e.+e² )
Assuming e is constant & that e² << R, elimination of e² yields:
P.R.= C.T
Or: Tension X wall thicknessPressure = ------------------------------Radius
P = intraluminal pressureR = radius of the spheree = wall thicknessT = wall tensionЛ = 22/7 or 3.14
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04/22/23
UPPER TRACT OBSTRUCTION
INVESTIGATION1. IVP2. USG3. RADIONUCLIDE (RENOGRAM)4. CT
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04/22/23
UPPER TRACT OBSTRUCTION
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04/22/23
UPPER TRACT OBSTRUCTION
INVESTIGATION1. IVP2. USG3. RADIONUCLIDE (RENOGRAM)4. CT
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04/22/23
UPPER TRACT OBSTRUCTION
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04/22/23
UPPER TRACT OBSTRUCTION
INVESTIGATION1. IVP2. USG3. RADIONUCLIDE (RENOGRAM)4. CT
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Figure : The effect of obstruction on the renogram curve. A, mild obstruction; b, moderate obstruction;c, high-grade obstruction.
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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
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UNEQUIVOCAL CHRONIC OBSTRUCTION
Primary mega ureterRetrocaval ureterRetroperitoneal fibrosisUrothelial tumorUreteric stoneUreteric stricture
CongenitalTuberculosisBilharzialIatrogenicRadiation
Retroiliac ureter
Ovarian vein syndromeEndometriosisExtrinsic obstruction
Bowel malignancies (e.g. colon)Pelvic malignancies (e.g.cervix)
PregnancyUreteroceleBladder cancerMalacoplakiaBPHProstate CaProcidentiaPelvic lipomatosisUrethral stricturePhimosis
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04/22/23
EQUIVOCAL CHRONIC OBSTRUCTION
UPJ stenosisPrimary megaureterVUJ stenosisUrinary diversionApparent ureteric stricturePregnancyInfective dilatationDuplication
Previous surgery:ureterolithotomyre-implantationpyelopasty
Previous endourology:ureteroscopybasketry
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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
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UPPER TRACT OBSTRUCTION
• Indications of emergency drainage– Obstructive anuria– Urosepsis caused by
• Pyonephrosis• Infected Hydronephrosis
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04/22/23
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