Obstruksi Upper Tract

transcript

04/22/23

Urinary Tract Obstruction

Dr marzuki yusuf SpU

CLASSIFICATION OF OBSTRUCTIVE UROPATHY

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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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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EQUIVOCAL CHRONIC OBSTRUCTION

UPJ stenosisPrimary megaureterVUJ stenosisUrinary diversionApparent ureteric stricturePregnancyInfective dilatationDuplication

Previous surgery:ureterolithotomyre-implantationpyelopasty

Previous endourology:ureteroscopybasketry

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• Indications of emergency drainage• Types of urinary drainage• Considerations in:

– type of the procedure – timing

• Case presentation

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• Types of emergency drainage– External: Nephrostomy

• Open • Percutaneous (PNS)

– Internal• Double-J stenting

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• 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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• Indications of emergency drainage– Obstructive anuria– Urosepsis caused by

• Pyonephrosis• Infected Hydronephrosis

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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

Obstruksi Upper Tract

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