REFERAT

OBSTRUCTIVE UROPATHY

Irfansyah

Pembimbing
dr.Danarto,SpB SpU
Definitions
 Obstructive uropathy :
Functional or anatomic obstruction of urine flow at any
level of the urinary tract

 Obstructive nephropathy :
When obstruction causes function or anatomic renal
damage
Incidence
 Frequency
– 3.8% (adults); 2.0% (children) postmortem examinations
– 20-35% prevalence in large survey among elderly men
 Sex
– No gender difference until 20 years
– Women 20-60; Men > 60
 Age
– Special considerations in pediatric patients
Etiology
 Types of obstruction
 Mechanical blockade
 Intrinsic
 extrinsic
 Functional defects
 Congenital
 Etiology

Within the lumen of
the Urinary tract:
-Stones
-Blood clot
-Tumors in the bladder,
renal pelvis & ureter
Within the wall of the
Urinary tract:
-Ureter neuromuscular
dysfunction
-Strictures (ureter,
uretoviscular)
-Urethra strictures
-Pin-hole meatus
Pressure on the urinary
tract from outside:
-Tumor (retroperitoneal,
colon)
-Diverticulitis
-Surgical ligation of the
ureters
-Prostate enlargement

In men the most common cause of obstruction is prostatic hypertrophy or cancer, stones,
urethral structures
In women the most common cause of obstruction is secondary to pregnancy & stones
 Pathophysiology
Obstruction
Long term intravesical pressure on the bladder

Hypertrophy of the trabeculation and cellule mucosal diverticula

muscle wall formation in the bladder wall

detrusor muscle decompensation

Inadequate emptying of the bladder Back pressure on the ureter

Urine stasis - compress the papillae Ureteral wall

Decreases GFR hypertrophy
trying to
Increases the risk for -Loss of nephrones
propel urine
infection
Renal parenchyma into the
bladder
Impaired renal function
Pathophysiology
Obstructive Uropathy

Obstructive Nephropathy
Hemodynamic Changes with Unilateral
Ureteral Occlusion
Triphasic pattern of renal blood flow and ureteral pressure
changes
 1. RBF increases during the first 1-2 hours and is accompanied
by a high PT and collecting system pressure
 2. For another 3-4 hours, the pressures remains elevated but
the RBF begins to decline
 3. 5 hours after obstruction, further decline in RBF occurs. A
decrease in PT and collecting system pressure also occurs
Triphasic pattern of UUO
Bilateral urinary obstruction (BUO)
• No triphasic pattern
• Modest increase in RBF after 90 min but between 90 min
to 7 hours, RBF is significantly lower than UUO.
• Increase renal vascular resistance (RVR)
 Ureteral pressure higher than in UUO
 Effective RBF is markedly decreased after 48 hours
 GFR is significantly decreased after 48 hours
Hemodynamic Changes with Bilateral
Ureteral Occlusion

 The intrarenal distribution of blood flow changes from the

inner to the outer cortex (opposite from UUO)
 Accumulation of vasoactive substances (ANP) in BUO that
contributes to preglomerular vasodilation and postglomerular
vasoconstriction
 With UUO, these substances would be excreted by the normal kidney

 When obstruction is released, GFR and RBF remain depressed

due to persisent vasoconstriction of the afferent arteriole
Pathophysiology of Bilateral Ureteral Obstruction
Hemodynamic Effects Tubule Effects Clinical Features
Acute
Renal Blood Flow ureteral and tubular pain
pressures
GFR azotemia
Medullary Blood Flow reabsorption of Na, Oliguria or anuria
urea, water
Vasodilator PGs
Chronic
Renal Blood Flow medullary osmolarity azotemia
GFR concentrating ability hypertension
vasoconstrictor PGs Structural damage; ADH-insensitive polyuria
parenchymal atrophy
renin-angiotensin pdn transport fxn for Na,K, Hyperkalemic,
H hyperchloremic acidosis
Pathophysiology of Bilateral Ureteral Obstruction
Release of Obstruction
Slow in GFR (variable) Tubular pressure
solute load per nephron
(urea, NaCl)
Natriuretic factors present
Postobstructive diuresis
Potential for volume
depletion and electrolyte
imbalance due to losses of
Na, K, PO4, Mg and water
 Symptoms & Signs
Symptoms & signs of Upper Urinary Symptoms & signs of lower UT obstruction
tract obstruction
Symptoms Symptoms
Loin pain Straining to void

Anuria Hesitancy

Haematuria urine stream

Physical findings nocturia

Enlarges Kidney Sense of incomplete bladder emptying

Pelvic masses the obstruct the Post-void dribbling

ureter Urge incontinence
Urine extravasations presented as Supra-pubic pain
ascitis
Signs
Supra-pubic mass

Rectal Exam  enlarged prostate

Meatal stenosis
History

– Medication history
• Antihistamines, antipsychotics, antidepressants
• Ethylene glycol, indinavir, methotrexate, phenylbutazone, or
sulfunamides
• Methysergide or other natural-occurring ergotamines
– Occupational exposure history
• Textile manufacturers, shipyard workers, roofers or asbestos
miners (retroperitoneal fibrosis)
• Textile workers, rubber manufacturing workers, leather
workers, painters, hairdressers, drill press workers (bladder
cancer)
Physical Examination

 Signs of dehydration and intravascular volume depletion

 Peripheral edema, hypertension, signs of congestive heart
failure
 Palpable kidney or bladder
 Enlargement of pelvic organs (eg. Prostate, uterus)
 Examination of external urethra for phimosis, meatal stenosis
 Investigations
 Urinalysis to detect:
 Pyuria : WBCs in urine that suggests inflammation
 Haematuria suggesting infection, stones or tumors
 Urine cytology if tumor is suspected

 Serum electrolytes to detect:

 Renal insufficiency by  Urea & creatinine due to GFR
 Electrolyte imbalance (hyperkalemia and acidosis) due to  renal
clearance of K+ and H+

 CBC to detect
 anemia of chronic disease
Imaging studies
1. Ultrasound:
Dilated collected system & distended bladder
secondary to obstruction
May have false negative in acute obstruction (35%)

2. CT scan:
Not very clear anatomical details of urinary tract. Used
if external compression of urinary tract

3. Intravenous Urography
Applies anatomic and functional information
Imaging studies
4. Antegrade pyelography:
For diagnostic opacification of the renal collecting system or for
aspiration in pyonephrosis
5. Retrograde pyelography:
Gives accurate details of ureteral and collecting system anatomy
Good if renal insufficiency or other risks for contrast
Imaging studies
6. Nuclear Renography
 Provides functional assessment without contrast
 Obstruction is measured by the clearance curves
 Tc 99m DTPA- glomerular agent
 Tc 99m MAG3 – tubular agent

 Diuretic renogram- maximizes flow and distinguishes true

obstruction from dilated and unobstructed

Normal = T ½ < 10 min Indeterminate = T ½ 10-20 min Obstructed T ½ > 20 min

Management
 The first goal of therapy is relief of the obstruction
Definitive therapy often requires surgery, but minimally
invasive techniques are becoming utilized more often.

 Medical therapy (supportive therapy)

 Analgesics
 Antibiotics
Management
 Management for lower Urinary tract
 Urethral catheter
 Supra-pubic catheter

 Management for upper Urinary tract

 Ureter stents: endoscopicaly placed tube from the renal pelvis to
the bladder
 Percutaneous nephrostomy: small tube placed in the renal pelvis,
ureter, bladder.
INDICATIONS
There are 4 broad indications
for the placement of a
Percutaneous nephrostomy :
(1) relief of urinary
obstruction,
(2) diagnostic testing,
(3) access for therapeutic
interventions, and
(4) urinary diversion
INDICATIONS
 Stents are often inserted to relieve either extrinsic
(tumor, retroperitoneal fibrosis) or intrinsic ureteral
obstruction (stones, tumors, strictures) as a temporary
measure while definitive treatment is instituted or as
permanent measure when no corrective treatment is
possible.
 In the context of bilateral obstruction, solitary kidney
(anatomic or functional), refractory renal colic or
obstruction associated with infection (fever, leukocytosis,
pyuria) stent placement to secure drainage is often an
emergent absolute indication
Complications
 Urinary tract infection
 Stone formation
 Renal parenchyma loss  renal insufficiency and renal
failure
 Bladder decompensation  neurogenic bladder
Renal Recovery after Obstruction
 Degree of obstruction, age of patient, and baseline
renal function affect chance of recovery
 Two phases of recovery may occur
 Tubular function recovery
 GFR recovery

 Duration has a significant influence

 Full recovery of GFR seen with relief of acute complete
obstruction
 Longer periods of complete obstruction are associated
with diminished return of GFR

 DMSA scan is predictive of renal recovery

Prognosis
 The prognosis 'depends on the cause, site, duration, and
degree of kidney damage and renal decompensation.
 With relief of obstruction
 Reversible or irreversible damage?
 Obstruction NOT relieved
 Complete or incomplete?
 Bilateral or unilateral?
 Presence or absence of infection
Summary
 Obstructive uropathy is an important urologic disorder
and a common cause of acute and chronic renal failure
 Multiple causes, high clinical suspicion and acumen
necessary
 Obstructive uropathy is a potentially reversible process
 Prompt recognition
 Prompt treatment
 Prompt consultation/referral
Urgent evaluation
A. Clinical history : 1. number of renal moeities 2.History of diabetes 3.Underlying renal insufficiency 4.Symptoms of infection (fever,
chills, etc) 5.is patient pregnant? 6. prior urologic or surgical procedure 7. contrast allergy
B. Physical examination : 1. Surgical abdomen 2. Sign of sepsis 3.Is patient pregnant? 4. Signs of fluid overload
C. Laboratory testing: 1 renal insufficiency 2. renal failure 3. Hyperkalemia 4. Pregnancy testing 5.Urinary tract infection 5. Leucocytosis
D. Diagnostic imaging : 1.Abscess 2. Air in collecting system (i.e emphesematous pyelonephritis) 3. nonurologic cause of symptoms

Diagnosis
A. Unilateral upper tract obstruction
B. Bilateral upper tract obstruction

Immediate drainage required No immediate drainage required

Indications:
1. Complete obstruction
2. Obstruction with infection
3. Obstruction with renal failure Additional work Diagnostic work
4. Obstruction with solitary kidney up required up complete
5. Obstruction with renal allograft
6. Obstruction with pregnancy

Urologic No primary Immediate

Retrograde stent Percutaneous treatment urologic treatment definitive
pacement nephrostomy indicated indicated treatment

Other medical
treatment Follow up based
Correct problems warranting urgent Delayed urologic
on etyology of
drainage treatment
obstruction
Algorithm for managing AUR Patient in AUR

Previous LUTS ?
History

Painful UR? Abdominals, Genital

Excess alcohol/ fluid Examination

intake?
Focused neurological
including anal tone
Manage as por benigna
Malignant
DRE

Manage as por benign, Faecal loading? Ultrasound, Assestment

but ensure treatmet in
of Residual urine
place and do not TWOC
until bowel managed Benigna Catheterize
If urethral catheterization
impossible,consider
urethral stricture, insert
TURP/retropubic Urethral or suprapubic catheter suprapubic catheter and
prostatectomy if arrange retrograde
uretrography
symptoms deteriotae
RU <1000ml RU > 1000ml Ultrasound
ἀ antagonist ± 5ἀ High pressure examination of
Review in clinic 3 upper urinary tract
reductase inhibitor if chronic
months with flow rate
gland >40cm³ Serum Cr normal Serum cr elevated retention
dan RU measurement

Monitor K and
Voids (RU<200ml) TWOC 24-72 hours Ensure definitive treat if elevated
bladder drainage

Long term urethral or

Fail to void VCMG Obstructed
suprapubic catheterize
TURP/retropubic
prostatectomy if fit
RU > 200ml CISC Unobstructed

RU : residual urine
AUR acute urine retention
TWOC : Trial without catheter
VCMG : Video cystometogram
CISC : Clean intermittent catheterization
Terima kasih
Hemodynamic Changes with Unilateral
Ureteral Occlusion

 Alterations in flow dynamics within the kidney occur dye

to changes in the biochemical and hormonal milieu
regulating renal resistance
 Phase I- The increased PT is counterbalanced by an increase in renal
blood flow via net renal vasodilation, which limits the fall of GFR
 PGE2, NO – Contribute to net renal vasodilation early in UUO
 Phase II and III- An increase in afferent arteriolar resistance occurs
causing a decrease RPF. A shift in RBF from the outer cortex to the
inner cortex also occurs all reducing GFR
 Angiotensin II, TXA2, Endothelin - mediators of the preglomerular
vasoconstriction during the 2nd and 3rd phase of UUO
Summary of UUO and BUO
Partial Ureteral Occlusion
 Changes in renal hemodynamics and tubular function are
similar to complete models of obstruction
 Develop more slowly
 Animal Studies- Difficult to imitate partial obstruction
 14 days- normal functional recovery
 28 days- recover 31% of function
 60 days- recovery 8% of function
Management of Patients with Obstruction
Diagnostic Imaging

 Renal US
 Safe in pregnant and pediatric patients
 Good initial screening test
 No need for IV contrast
 Hydronephrosis= anatomic diagnosis
 Can have caliectasis or pelviectasis in an unobstructed system
 Doppler- measures renal resistive index (RI), an assessment
of obstruction
 RI= (PSV-EDV)/PSV
 RI > 0.7 is suggestive elevated resistance to blood flow suggesting
obstructive uropathy
 Diagnostic Imaging
 Whitaker Test
 “True pressure” within the pelvis = Collecting system
pressure – intravesical presure
 Saline or contrast though a percutaneous needle or nephrostomy
tube at a rate of 10mL/ min
 Catheter in bladder to monitor intravesicle pressure
 Invasiveness and discordant results limit clinical usefulness

Normal < 15 cm H2O Indeterminate = 15-22 cm H2O Obstruction > 22 cm H2O

 Diagnostic Imaging
 CT
 Most accurate study to diagnose
ureteral calculi
 More sensitive to identify cause of
obstruction
 Helpul in surgical planning
 **Preferred initial imaging study in
those with suspected ureteral
obstruction
 MRI
 Can identify hydro but unable to
identify calculi and ureteral anatomy
of unobstructed systems
 Diuretic MRU can demonstrate
obstruction
 Especially accurate with strictures or
congential abnormalities
 IV gadopentetate-DTPA allows
functional assessment of collecting
system while providing anatomic
detail
 GFR assessment
 Renal clearance
 Still several limitations in its use
Issues in Patient Management

 Renal Drainage
 Endourologic or IR procedures allow prompt temporary and
occasionally permanent drainage
 No statistically significant difference in HRQL between the two
techniques
 Patients with extrinsic compression causing obstruction have a high risk
of ureteral stent failure
 42-56.4 % failure rate at 3 months
 43% failed within 6 days of placement in one study
 High failure rate at even getting placement(27%)
 Stent diameter did not predict risk of failure
 Ultrasound guided percutaneous drainage should be initial
consideration in pregnant patients
 Percutaneous placement with suspected pyonephrosis
 Large diameter ureteral stents
Issues in Patient Management
Considerations in Surgical Intervention

 Reconstruction
 Endoscopic, open and laparoscopic techniques should
be considered
 Need for nephrectomy?
 Allow 6-8 weeks for adequate drainage before proceeding
 Nuclear imaging provides accurate functional information
 < 10% contribution to global renal function is considered
threshold for nephrectomy
Issues in Patient Management
Pain

 Increases in collecting system pressure and

ureteral wall tension contribute to renal colic
 Results in spinothalamic C-fiber excitation
 Treating Pain
 Narcotics
 Rapid onset, nausea, sedation, abuse
 NSAIDS
 Targets the inflammatory basis of pain by inhibiting prostaglandin
synthesis
 Reduces collecting system pressure by decreasing renal blood
flow
 Avoid in patients with renal insufficiency, GI bleeds
Issues in Patient Management
Postobstructive Diuresis

 A normal physiologic response to volume

expansion and solute accumulation
 Elimination of sodium, urea, and free water
 Diuresis ends when homeostasis returns
 Pathologic postobstructive diuresis
 Impaired concentating abilility or sodium absorption
 Downregulation of sodium transporters and sodium reabsorption
in the thick ascending loop of Henle
 Increased production and altered regulation of ANP
 Poor response of collecting system to ADH
Post-operative considerations
 After the relieve of a long standing obstruction, diuresis
occur due to:
 Water overload
 Osmotic affect of retained salt
 Defect in the renal reabsorption capacity
 Diuresis is self-limiting but some patients may develop
severe hyponatremia, hypokalemia, alkalosis & dehydration
& may require IV replacement.
Issues in Patient Management
Postobstructive Diuresis

 Management
 Monitor those with BUO or UUO in solitary kidney for
POD
 Electrolytes, Mg, BUN, Cr
 Intensity of monitoring depends on clinical factors
 If no signs of POD If alert, no fluid overload, normal renal function,
normal lytes,  discharge and follow up
 If signs of POD  If alert, able to consume fluids, normal VS
continue in-patient observation, free access to oral fluids, and daily
labs until diuresis resolves (No IV Fluids)
 If signs of POD and signs of fluid overload, poor renal function,
hypovolemia, or MS changes Frequent VS and u.o records, labs q 12
hrs (or more), urinary osmolarity, restrict oral hydration (Minimal IV
fluid hydration)
 Most have self-limiting physiologic diuresis
 If pathologic diuresis occurs- very intense monitoring is indicated