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Management of Upper Urinary Tract Obstruction: Difference between revisions

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== Ureteropelvic junction obstruction ==
== Ureteropelvic junction obstruction ==


* '''See Pediatrics Surgery of the Ureter Chapter Notes'''
* '''See [https://test.urologyschool.com/index.php/Pediatrics:_Surgery_of_the_Ureter#Ureteropelvic_Junction_Obstruction_(UJPO) Ureteropelvic Junction Obstruction Section] in [[Pediatrics: Surgery of the Ureter|Pediatrics Surgery of the Ureter Chapter Notes]]'''


=== Etiology ===
=== Etiology ===
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*# '''<span style="color:#0000ff">S</span><span style="color:#ff0000">tones</span>'''
*# '''<span style="color:#0000ff">S</span><span style="color:#ff0000">tones</span>'''


=== Diagnosis and evaluation ===
=== Diagnosis and Evaluation ===
* '''Imaging'''
 
** Performed to determine the anatomic site and functional significance of an apparent obstruction
==== History and Physical Exam ====
** '''Diuretic renography'''
 
***'''Commonly used''' for diagnosing both UPJ and ureteral obstruction  
*'''History'''
***'''Provides quantitative data regarding differential renal function and obstruction,''' even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''
**'''<span style="color:#ff0000">Signs and Symptoms</span>'''[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]
**** '''<span style="color:#ff0000">In general, kidneys with < 15% differential function are nonsalvageable in adults</span>''' (Chapter 48 suggests <10%)'''.'''
**# '''<span style="color:#ff0000">Periodic abdominal pain (loin pain), usually after diuresis'''
***** '''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''
**# '''<span style="color:#ff0000">Vomiting'''
**# '''<span style="color:#ff0000">Recurrent pyelonephritis'''
**# '''<span style="color:#ff0000">Fever'''
**# '''<span style="color:#ff0000">Uncommonly, abdominal mass, or hematuria secondary to infection'''
 
==== Imaging ====
* Performed to determine the anatomic site and functional significance of an apparent obstruction
* '''Diuretic renography'''
**'''Commonly used''' for diagnosing both UPJ and ureteral obstruction
**'''<span style="color:#ff0000">Most commonly used agent in renogram studies is technetium 99m mercaptoacetyltriglycine (99m Tc-MAG3), especially in the pediatric population[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]'''
***In the adult population, other agents can be used, such as diethylenetriamine pentaacetate (DTPA)
**'''<span style="color:#ff0000">Provides quantitative data regarding differential renal function and obstruction</span>''', even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''
*** '''<span style="color:#ff0000">In general, kidneys with < 15% differential function are nonsalvageable in adults</span>''' (Chapter 48 suggests <10%)'''.'''
**** '''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''


=== Management ===
=== Management ===
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***'''<span style="color:#ff0000">The Foley catheter is usually removed 24 to 36 hours postoperatively, and the surgical drain is removed before hospital discharge if the drain output remains negligible.</span>'''
***'''<span style="color:#ff0000">The Foley catheter is usually removed 24 to 36 hours postoperatively, and the surgical drain is removed before hospital discharge if the drain output remains negligible.</span>'''
**** '''<span style="color:#ff0000">If the drain output increases after the Foley catheter removal, the Foley catheter should be replaced for 7 days to eliminate urinary reflux along the stent in the treated ureter and decrease urinary extravasation at the ureteropelvic anastomosis.</span>'''
**** '''<span style="color:#ff0000">If the drain output increases after the Foley catheter removal, the Foley catheter should be replaced for 7 days to eliminate urinary reflux along the stent in the treated ureter and decrease urinary extravasation at the ureteropelvic anastomosis.</span>'''
*** '''<span style="color:#ff0000">The ureteral stent is typically removed 4-6 weeks later in an outpatient setting, and follow-up including the use of imaging studies such as diuretic renal scan is performed</span>'''
*** '''<span style="color:#ff0000">Ureteral stent is typically removed 4-6 weeks later in an outpatient setting</span>'''
***'''<span style="color:#ff0000">Follow-up including the use of imaging studies such as diuretic renal scan is performed</span>'''
** '''Complications'''
** '''Complications'''
***'''Late'''
***'''Late'''
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**** '''Recurrent obstruction'''
**** '''Recurrent obstruction'''
*****'''Most failures from laparoscopic pyeloplasty occur in the first 2 years.'''
*****'''Most failures from laparoscopic pyeloplasty occur in the first 2 years.'''
***** '''<span style="color:#ff0000">For patients who fail laparoscopic pyeloplasty, open surgery has been used as a salvage procedure. However, most patients can be well managed with endoscopic intervention</span>'''
***** '''<span style="color:#ff0000">Management</span>'''
******'''<span style="color:#ff0000">Options (2)</span>'''
*******'''<span style="color:#ff0000">Repeat pyeloplasty (open surgery has been used as a salvage procedure after failed laparoscopic pyelopasty)</span>'''
*******'''<span style="color:#ff0000">Endoscopic intervention (most patients can be managed</span>'''  


==== Ureterocalicostomy ====
==== Ureterocalicostomy ====
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