OBSTRUCTIVE UROPATHY

1. OBSTRUCTIVE UROPATHY By ;Dr ESSIEN Dept of surgery NHA

2. Outline • Definition • Pathophysiology • Causes • Presentation • (Ix, Treatment)

3. DEFINITION • Obstruction to urine flow which causes deterioration of renal function

4. Types • Lower urinary tract obstruction(LUTO)- obstruction to urine flow from bladder neck to ext urethral meatus • Upper urinary tract obstruction(UUTO)-obstruction to urine flow from ureteric orifice up to kidneys

5. Pathophysiology-LUTO -1 • Urethra-narrow, lengthened, tortous,outflow resistance • Bladder- hypertrophy, trabeculation sacculation, diverticulum, atony,residual urine, retention,ca

6. Pathophysiology-LUTO-2 • Ureter-hydroureter, kinking • Kidney-hydronephrosis, renal failure • General- stasis,infection, calculi,ca

7. Pathophysiology-UUTO • Increased peristalsis→Hypertrophy of ureteral musculature • Progressive back pressure →hydroureteronephrosis • Elongation and tortuosity of the ureter • The ureter may become so attenuated as to resemble a loop of bowel. • ↑ intra renal pressure → ↓renal blood flow, ↓GFR , loss of nephrons. • Significant cortical atrophy is associated with functional renal impairment. • Post obstructive diuresis.

8. CAUSES- LUTO IN ADULTS • Mechanical obs urethra- US, BPH, Ca P, Bladder neck dyssernegia, Ca bladder, stones, urethral ca, meatal stenosis, BN contracture • Inflammation • Trauma • Neurogenic

9. CAUSES- LUTO IN CHILDREN • Meatal ulcer with scabbing • Meatal stenosis/ congenital urethral stricture • PUV • Phimosis,Paraphimosis • Stones • Urethral ca, rupture • Foreign bodies • Bladder neck dyssernergia • Neurogenic- SB

10. CAUSES- LUTO IN FEMALES • Post-op • Retroverted gravid uterus, impacted pelvic mass, fibroids • Ca bladder, calculi, • Urethral caruncle, urethral rupture • Bladder neck dyssernergia • Neurogenic bladder-Multiple sclerosis etc • Hysteria Dakum NK

11. UUTO-Unilateral hydronephrosis • Intramural-PUJ obs,cong stenosis, stricture, ureterocoele,cong small ureteric orifice, ca (bladder, ureter) ,megaureter, • Intraluminal-stone,sloughed papilla • Extramural-adjacent ca,idiopathic retroperitoneal fibrosis, retrocaval ureter

12. BILATERAL HYDRONEPHROSIS-CAUSES • All causes of LUTO • All causes of UUTO occurring bilaterally

13. B- PUJ obs

14. Aberrant vessel-treated by Hellstrom technique

15. Retrocaval ureter

16. Presentation-LUTO • Irritative- frequency, urgency, nocturia, urge incontinence, pain on micturition, nocturia. • Obstructive- delay, straining, poor stream, overflow incontinence, dribbling, sense of incomplete voiding, intermittency. • Others - haematuria, etc • Fxs of underlying cause & CRF

17. Presentation-UUTO • Loin pains, colics, haematuria, fxs of UTI, • Hydronephrosis • Fxs of underlying cause & CRF

18. Investigation • Assess renal function • Radiology- • plain abd x-ray • USS • Contrast-IVU, urethrocystography • CT, MRI • Endoscopy • Ix depending on cause

19. Treatment • Optimize renal function • LUTO- Catheter, SPC • UUTO- J-J stent, Percutaneous nephrostomy, ureterostomy • Low protein diet if CRF • Fluid balance if CRF • Treat infection, anaemia, renal failure, etc • Treat cause

20. summary • Defn-Obstruction + renal impairment • From upper or lower UT obstruction • Eventually upper tract affected • Treatment depends on cause • Necessary to detect early to prevent complications esp renal failure

21. THANK YOU!!!

22. ‘You weren’t put on earth to be remembered.You were put here to prepare for eternity.’-Rick Warren