Pujo

Prepared By:
Ahmed Ebrahim Helmy

- Remember!
-- Definition
- Epidemiology
- Etiology
-- pathophysiology
-- Presentation
- Complications
-- Investigations
-- Diagnosis
-- Differential diagnosis
- Management
- References

-The ureters are bilateral tubular structures
responsible for transporting urine from the renal
pelvis to the bladder .
-They are generally 22 to 30 cm in length with a
wall composed of multiple layers:
-transitional epithelium
-lamina propria
-smooth muscle(inner longitudinal and outer
circular)
Adventitia.-

Sites of ureteral
narrowing:
-Ureteropelvic junction.
-Junction as the ureter
crosses the iliac vessels.
-Ureterovesical junction.

-Ureteropelvic junction
(UPJ) obstruction is
defined as a partial or
complete obstruction of
the flow of urine from
the renal pelvis to the
proximal ureter.
-It can be congenital or
acquired.

-- UPJ obstruction is present in 50% of patients
diagnosed with antenatal hydronephrosis ,
occurring in 1 per 1000-2000 newborns.
-The male-to-female ratio of is 3-4:1.
-The left kidney is more commonly affected
than the right kidney.
- UPJ obstruction is less common in adults.
- UPJ obstruction is bilateral in 10% of cases.

--The condition is frequently encountered by
both adult and pediatric urologists.
- Congenital abnormalities may be observed in
both adults and children, but adults may also
present with UPJ obstruction secondary to
surgery or other disorders that can cause
inflammation of the upper urinary tract.
- Usually caused by intrinsic stenosis of the
proximal ureter, and less commonly by extrinsic
compression of the UPJ.

Intrinsic narrowing
- In most cases of UPJ obstruction, the upper segment
of the ureter is narrowed or kinked, resulting in
obstruction of urinary flow.
-The underlying mechanism is not proven.
-The most attractive theory is that the obstruction is
secondary to muscular discontinuity, which disrupts
the coordinated motion of smooth-muscle cells and
may result in impeded peristalsis propagation across
the UPJ and interference with urine bolus formation in
the proximal ureter.

Extrinsic narrowing
In about 10 % of pediatric UPJ obstruction, an
aberrant or accessory renal artery or arterial
branch may cross the lower pole of the
kidney, resulting in compression of the UPJ
and blockage of urinary flow or secondary to
surgery or other disorders that can cause
inflammation of the upper urinary tract.

-The urinary drainage from renal pelvis to ureter is
determined by many factors. Pressure within the renal
pelvis is determined by the volume of urine produced, the
internal diameter of the UPJ and collecting system, and
the compliance of the renal pelvis, as well as the peristaltic
activity of the ureter.
- In response to the increased volume and pressure, the
renal pelvis dilates. Initially, the smooth muscle of the
renal pelvis may thin out, but over time, it may become
hypertrophied to varying degrees.The effects on the
developing renal parenchyma may be quite variable,
owing to the compliance of the renal collecting system.
Despite massive dilation, preservation of renal function
may occur.

Intrauterine
Widespread use of antenatal
ultrasonography and the
advent of modern imaging
techniques have resulted in
earlier and more common
diagnosis of
hydronephrosis.
Neonates
Hydronephrosis

Older children
- Urinary tract infection
(UTI)
- Flank mass
- Intermittent flank pain
secondary to a primary UPJ
obstruction
- Hematuria if it is
associated with infection
Adults
- Back and flank pain correlates
with periods of increased fluid
intake ingestion of a food with
diuretic properties
- Urinary tract infection (UTI)
- Pyelonephritis
- Hypertension
- Abdominal mass
30% diagnosed after UTI
25% diagnosed after hematuria

Associations
10%-Vesicoureteral reflux
- imperferate anus
- contralateral multicyctic kidney
- congenital heart disease
- esophageal atresia

-Infected hydronephrosis
-Secondary stone formation
-Hematuria : Calcular or Malignant
-Increase Succeptibility to trauma
-Renal failure

Ultrasonography
(US)
Most cases of UPJ
obstruction present as a
result of detecting
hydronephrosis by
prenatal ultrasonographic
screening

Diuretic renography
-It (renal scan and the administration of a diuretic) is used to
diagnose urinary tract obstruction. It measures the drainage
time from the renal pelvis (referred to as washout) and assesses
total and each kidney's individual renal function.
-The washout measurement correlates with the degree of
obstruction.
-In general, a half-life greater than 20 minutes to clear the
isotope from kidney is considered indicative of the obstruction .

Computed tomographic scan (CT)
- It is an alternative to ultrasonography in the
symptomatic child.
-It is not the preferred modality due to its radiation
exposure.
- In UPJ obstruction, the CT scan typically shows
hydronephrosis without a dilated ureter.

Magnetic resonance imaging (MRI)
- It can be used to diagnose UPJ type hydronephrosis.
-The advantage of MRI is the ability to discern accurate
anatomy defining the point of obstruction.
-Also determine the split function of the kidney and simulate
the diuretic renogram by providing washout data.
-The disadvantage of MRI is the cost and the need for
general anesthesia and/or sedation.

Voiding cystourethrogram (VCUG)
-It is performed in patients with hydronephrosis to confirm the
presence or absence of VUR of both the affected and
contralateral kidneys.
-10% of patients with UPJ obstruction have contralateral low-
grade vesicoureteral reflux.
-Identification ofVUR is important because children with concurrent
VUR and UPJ obstruction may be at higher risk for severe
infection.

Others
Urine analysis
Serum creatinine

To Breif
-It is generally suspected when imaging studies,
usually ultrasonography, demonstrate
hydronephrosis.
-The diagnosis is confirmed by diuretic
renography.
-30% diagnosed after UTI
-25% diagnosed after hematuria
-Complications

causes of hydronephrosis
A)Obstructive causes
1)PUJO
2)Ureteral Obstruction
a-Lumen
b-wall
c-outside the ureter
3)Bladder
4)Urethra
5)Prostate
B)VUR

Different renal swellings
-Single or multiple simple renal cysts
-Multicystic kidney
-Polysystic kidney
-Renal tumors

Conservative
-Follow up with US
and/or renal scan every 3-
4 months for 1 year and
then every 4-6 months.
-VCUG to assessVUR
-Antibiotics ifVUR is
present
Principles
-50% of antenatal hydro resolved
postpartum .
-observations that asymptomatic
hydronephrosis can resolve
spontaneously.
-“Rule of 1/3” - 1/3 stay the same, 1/3
improve, 1/3 worsen.

Indications for Surgical Intervention
• Presence of symptoms associated with the
obstruction.
• Impairment of overall renal function.
• Progressive impairment of ipsilateral function.
• Development of stones or infection .
• Hypertension.

Open Pyeloplasty
– Gold Standard
– Dismembered pyeloplasty is the most
common

Foley V-Y-Pyeloplasty
– Good for 1-2 cm obstruction
– Best for high inserting ureter
– Best with relatively small pelvis

Spiral flap pyeloplasty
– Good for long obstructions (better in adults)
– Length of flap limited only by size of pelvis
• (keep length: width at 3:1)
• good when UPJ angle > 90

Endopyelotomy
– Antegrade or retrograde
– Cold knife or electric current
– Direct vision
– 86% success in adults
– Slightly less effective in children

Laparoscopic pyeloplasty
– Same indications as open or endourologic procedures
– Dismembered pyeloplasty is most common procedure
performed
_Without crossing vessels, may do any number of flap
procedures
_ Up to 94% success rate, similar to open pyeloplasty

https://emedicine.medscape.com/article/10169
88-clinical
http://urology.ucla.edu/body.cfm?id=478&ref=7
&action=detail

Pujo

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Ähnlich wie Pujo

Ähnlich wie Pujo (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Pujo