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Obstructive Uropathy

Definition Aetiology (Causes)

Obstruction of Urinary Tract Congenital
Lead to Renal Impairment Congenital Narrowing
Meatal stenosis
Classification Distal urethral stenosis
Causes – Congenital, Acquired Posterior urethral valve (PUV)
Duration – Acute, Chronic Ectopic ureters
Degree – Partial, Complete Ureterocoeles
Level – Upper Urinary Tract, Lower Urinary Tract Ureterovesical (VUJ)
Ureteropelvic Junctions (PUJ) Stenosis
Anatomy S2-S4 Sacral Root Damage
Spina Bifida
Myelomeningocoele
Vesicoureteric Reflux (VUR)
Acquired
Urethral stricture (Infection, Injury)
Benign Prostatic Hyperplasia (BPH)
Prostate Cancer
Bladder Tumour
(Bladder neck, Ureteral orifices)
CaP, Cervical cancer (CaCx)
(extension into base of bladder
occluding ureters)
Compression of Ureters at Pelvic Brim
by metastatic nodes from CaP, CaCx
Ureteral Stones
Retroperitoneal Fibrosis
Malignant Tumour
Pregnancy
Neurogenic Bladder

Pelvi-Ureteric Junction (PUJ) Obstr.

Stones

VUR

Bilateral VUR due to PUV

Staghorn Calculi

Bladder Outlet Obstruction (BOO)

Bilateral VUR 2° to
Prune Belly Syndrome

Tumours

Stricture
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Pathophysiol ogy Upper Tract Changes

Obstruction, Neuropathic Bladder Dysfun ction
have same effects on GUT
Lower Tract
Distal to Bladder Neck
Severe external urinary
meatal stricture
Bladder
BPH
Lower Tract Changes (Bladder)
↙ ↓
Diverticulum
Hydroureter (HU)
Hydronephrosis (HN)
Upper Tract Ureter
(Ureter, Kidney) Early Stages Late Stages
BPH Intravesical Pressure is Normal when Decompensation + Residual Urine
Bladder fills ↓
Pressure ↑ only in Voiding Added Stretch Effec t
↓
Pressure is not Transmitted to Incompetence of VUJ valves
Ureters, Renal Pelves because ↓
competence of VUJ valves VUR
Trigonal Hypertrophy ↓
↓ Further Hyd roureteronephrosis
↑ Resistance Urine Flow 2° to Back Pressure
Obstruction ↓ (due to reflux, obstruction)
↓ Progressive Back Pressure on ↓
↑ Hydrostatic Pressure Ureter, Kidney Ureteral Musculature Thickens
↓ ↓ (push urine downward by peristaltic
Hydroureter, Hydronephrosis activity – Compensation Stage)
Dilation of Urethra
↓
↘ Elongation, Tortousity of Ureter
Prostatic Duct Dilation Infected Urine Fibrous tissue band formation
↓ ↓

Extravasation Further Angulate Ureter

(during contraction)
↓ ↓
Periurethral Abscess 2° Ureteral Obstruction
At this stage, removal of obstruction below
may not prevent Kidney from undergoing
progressive obstruction
Ureteral Wall Attenuated
(due to ↑ Pressure)
↓
Contractile Power is Lost
(Decompensation stage)
↓
Severe Ureteral Dilatation
(like Bowel Loops)
Kidney
Normal Kidney Pressure ≈ 0
When Pressure ↑ - Pelvis, Calyces Dilate
2 Stages (depend on d uration, degree, site)(the higher, the greater effect on Kidney)
Compensation Decompensation If Intrarenal Pelvis - Parenchyma affected (compared to extrarenal)
Bladder musculature Hypertrophy Decompensation of Early Stage Later Stage
(to balance ↑ urethral resistance) Detrusor Muscle results in Pelvic musculature Hypertrophy Muscle become Stretched
Trabeculation of Bladder Wall presence of Resid ual Urine (RU) (to force urine past obstruction) ↑ Atonic (Decompe nsated)
Cellules after voiding Progression of Hydronephrotic Atrophy
Diverticula Earliest change – Calyceal Hydronephrosis
Mucosal changes With ↑ Pressure, Normal Concave Calyx
Trabeculation of Bladder Wall become Flattened then become Convex (clubbed)
Normal Mucosa – Smooth Renal Parenchymal changes due to
Hypertrophy • Compression atrophy (from ↑ Intrapelvis Pressure)
↓ • Ischaemic Atrophy (from Haemodynamic changes)
Individual muscles bundle become taut (manifested in Arcuate vessels that run at base of Pyramids) → Spotty Atrophy
↓ Tubules become Dilated
Coarse interwoven appearance
Cells Atrophy from Ischaemia
Trigonal muscle, Interureteric ridge Hypertrophy Hydronephrosis (un usual type of Pathologic change)
↓ Only in Unilateral Hydronephrosis
↑ Resistance urine flow in Intravesical ureteral segments Advanced stages of Hydronephrotic Atrophy is seen
↓ Eventually, Kidney become
Functional obstruction of VUJ Completely Destroy ed
↓
Back Pressure on Kidney Appears as Thin-Walled Sac filled with Clear Fluid, Pus
↓ ↑ Intrarenal Pressure
Hydroureter, Hydronephrosis Cause Suppression of Renal Function
The Closer Intrapelvic Pressure approaches Glomerular Filtration Pressure
Obstruction ↑ in the presence of Significant Residual Urine The ↓ Urine can be secreted
Cellules GFR, RBF ↓
Mucosa between Superficial Muscle Bundles is Pushed Concentrating Power is Gradually Lost
↓ Urea/Creatinine Ratio ↓ (compared to Normal Kidney)
Formation of Small Pockets (Cellules) Completely Obstructed Kidney
Diverticula Continue to secrete Urine (which is reabsorbed via Tubules, Lymphatics)
Cellules force through entirely the musculature of Bladder Wall (Normally – other secreting organs – cease sec reting when completely obstructed)
↓ Intrapelvic Pressure ↑ Rapidly
Saccules ↓
↓ Extravasation of Urine from Renal Pelvis into Parenchymal Interstitium
Diverticula (reabsorbed by lymphatics)
↓
May be embedded in Perivesical Fat or covered by Peritoneum ↓ Intrapelvic Pressure
(depending on location) (Allow Further Filtration)
Unable to expel content efficiently into Bladder after 1° obstruction has been removed Compensation
(No Muscle Wall) Markedly Hydronephrotic Kidney continue to Function
Does not contain true urine (only H2O, Salts)
As Unilateral Hydronephrosis Progress
Normal Kidney undergo compensatory hypertrophy (Maintain Total Renal Function)
Successful Anatomical Repair of Obstruction of Kidney
Fail to Improve Powers of Elimination
If Both Kidney Equally Hydronephrosis
Strong Stimulus Continually Exerted on Both to Maintain Maximum Function
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Clinical Features Recovery of Function

Loin Pain (due to Capsule Stretch, Presence of Calculu s, Infection ) Depend on
Ureteric, Renal Colic Degree of Obstruction
Complete Anuria Duration of Obstruction
Complete Bilateral Obstruction Prevent Renal Impairment
Complete Obstruction of Single Functioning Kidney Relief of Complete Urinary Obstruction should be achieved expediently
Polyuria Decompress Urinary System Temporarily
Partially Obstruction – impairment of Renal Tubular Concentrating Ability Temporary Drainage device
Hematuria (Microscopic/ Occult) Until Management can be executed
Urinary Stones Obstruction & Infection
Malignancy Urological emergency
Infection Require
Uraemia • Immediate relief
Bilateral Obstruction, Obstruction of a solitary Kidney (Foley Catheter, Ureteral Stent, Percutaenous Nephrostomy Tube)
Results in • Broad spectrum Antibiotics (prevent Life-threatening Urosepsis)
• Weakness
• Pallor Relieve Obstruction (Decompress Upper Tract Obstruction)
• Weight Loss Ureteral Stent Percutaenous Nephrostomy
• Peripheral Edema Small tube Small Tube
• Mental status change Renal Pelvis → Bladder Placed through Flank
(placed endos copically, with Directly into Renal Pelvis
Investigations Fluoroscopic guidance ) (percutaneously by Urologist,
KUB X-Ray Performed in Operating Room (OR) Interventional Radiologist)
Renal Function Test (RFT) Under Local Anaesthesia (LA) Require only Local Anaesthesia (LA)
Urine Adequate Sedation
Full Microscopic Examination (FEME)
Culture, Sensitivity (C&S)
Ultrasound
KUB
Urinary Tract
Intravenous Urography (IVU)
CT Urography/ CT Renal Protocol
Retrograde Pyelography (RPG)
Antegrade Pyelography (APG)
DTPA
DMSA
Complications
Treatment Pyelonephritis, Pyonephrosis
Aims (eg. gross pus within obstructed renal pelvis of a funtionless kidney)
Relieve Obstruction Abscess formation
Treat Underlying Cause Urosepsis
Prevent, Treat Infection Urinary Extravasation with Urinoma Formation
Relief Symptoms Urinary Fistula Formation
Preserve Renal Function Renal Parenchymal Loss
Depend on (long term obstruction leading to renal insufficiency, failure)
Degree of Obstruction
Renal Impairment
Infection
Site of Obstruction
Expeditious Intervention, Hos pitalization
Complete Obstruction
Obstruction of a Solitary Kidney
Infection (Fever, Leukocytosis, Bacteriuria)
Azotemia Pyonephrosis
Uncontrolled Colic Pain
Nausea, Vomiting, Dehydration Prognosis
Depend on
Medical Treatment Cause
Analgesics Antibiotics Site
Voltaren Bactrim Degree (partial, complete)
Pethidine Trimethoprim Duration of Obstructive process
Presence of Concomitant Infection
Zinnat
Favourable Prognosis Expected if
Ciprobay
Renal Function Good
Obstruction Corrected
Infection Eradicated