Obstructive Uropathy. PATHOPHYSIOLOGIC CHANGES UUO vs BUO. Arry Rodjani Urology Department Ciptomangunkusumo Hospital Jakarta

Transcription

1 Obstructive Uropathy PATHOPHYSIOLOGIC CHANGES UUO vs BUO Arry Rodjani Urology Department Ciptomangunkusumo Hospital Jakarta

2 INTRODUCTION Obstructive uropathy refers to the functional or anatomic obstruction of urinary flow at any level of the urinary tract Obstructive nephropathy is present when the obstruction causes functional or anatomic renal damage Hydronephrosis is the dilation of the renal pelvis or calyces. It may be associated with obstruction but may be present in the absence of obstruction 2

3 INTRODUCTION Urinary Tract Obstruction tubular pressure changes, renal blood flow, and glomerular filtration rate affecting the excretion function and renal homeostasis irreversible renal impaired 3

4 INCIDENS Obstruction of the urinary tract may occur during fetal development, childhood, or adulthood In Indonesia mostly caused by stone in the urinary tract 4

5 Posible causes of obstructive nephropathy Renal Congenital Inflamatory Polycystic kidney, renal cyst, aberrant vessel at ureteropelvic junction Wilms tumor, renal cell ca, TCC of the renal pelvis, multiple myeloma Tuberculosis Metabolic Calculi Neoplastic Miscellaneous Sloughed papillae, trauma, renal artery aneurism 5

6 Posible causes of obstructive nephropathy Ureter Congenital Neoplastic Inflamatory Stricture, ureterocele, ureterovesical reflux, ectopic kidney, retrocaval ureter, Prune-Belly syndrome Primary carcinoma of ureter, metastatic carcinoma Tuberculosis, abscess, ureteritis cystica, endometriosis Miscellaneous Retroperitoneal fibrosis, pelvic lipomatosis, radiation therapy, lymphocele, trauma, urinoma, pregnancy 6

7 Posible causes of obstructive nephropathy Bladder and Urethra Congenital Posterior urethral valve, phimosis, urethral stricture Neoplastic Bladder ca, prostate ca, ca of urethra, ca of penis Inflamatory Prostatitis, paraurethral abscess Miscellaneous Benign prostatic hyperplasia Neurogenic bladder 7

8 SYMPTOMS Wide range symptoms, depend on: Acute / chronic Unilateral / bilateral The cause of obstruction (extrinsic vs intrinsic) Complete obstruction / parsial obstruction Presence or absence of infection Compliance of collecting system 8

9 Pathophysiologic changes UUO vs BUO 9

10 10

11 UNILATERAL URETERAL OBSTRUCTION (UUO) 1.Acute phase (1-2 hrs) 2.Mid phase (2-5 hrs) 3.Later phase (5-24 hrs) 11

12 Triphasic relationship between ipsilateral renal blood flow and left ureteral pressure during 18 hours of left-sided occlusion 12 Pais V, In Walsh PC, Campbell s Urology, WB Saunders 2007;37:

13 Summary of the functional changes during and following ureteral obstruction 13 Pais V, Pathophisiology of Urinary Tract Obstruction In Walsh PC, Campbell s Urology, WB Saunders 2007;37:

14 BILATERAL URETERAL OBSTRUCTION (BUO) This difference between the two pathophysiologic conditions due to an accumulation of vasoactive substances in BUO that could contribute to preglomerular vasodilation and postglomerular vasoconstriction. Such substances would not accumulate in UUO as they would be excreted by the contralateral kidney It is proved ==> diuresis and natriuresis after release of obstruction 14

15 Summary of the functional changes during and following ureteral obstruction 15 Pais V, Pathophisiology of Urinary Tract Obstruction In Walsh PC, Campbell s Urology, WB Saunders 2007;37:

16 Summary of the functional changes during and following ureteral obstruction Unilateral Bilateral or Solitary Kidney 16 Pais V, In Walsh PC, Campbell s Urology, WB Saunders 2007;37:

17 Summary of the functional changes during and following ureteral obstruction Unilateral Bilateral or Solitary Kidney 17 Pais V, In Walsh PC, Campbell s Urology, WB Saunders 2007;37:

18 Summary of the functional changes during and following ureteral obstruction Unilateral Bilateral or Solitary Kidney 18 Pais V, In Walsh PC, Campbell s Urology, WB Saunders 2007;37:

19 RENAL FUNCTIONAL CHANGES AFTER RELEASE OF OBSTRUCTION Tubular renal function changes after the release of obstruction depends on whether the obstruction is unilateral or bilateral After elimination of complete bilateral obstruction natriuresis and diuresis post-obstructed diuresis 19

20 RENAL FUNCTIONAL CHANGES AFTER RELEASE OF OBSTRUCTION GFR became normal after 1 week obstruction released. Not all nephrons hyperfiltration occur are in functionally normal reversible nephrons as a compensatory mechanism GFR back to normal level 20

21 Summary of major pathways leading to tubulointerstitial fibrosis and tubular apoptosis as a consequence of ureteral obstruction 21 Pais V, In Walsh PC, Campbell s Urology, WB Saunders 2007;37:

22 22

23 DIAGNOSIS 23

24 MANAGEMENT The management is performed to : (a) relief pain (b) recover or maintain renal function (c) avoid complication 24

25 Indication to release obstruction Unilateral obstruction Bilateral obstruction Pain unrelieved by analgesics Same as for OUU or Signs and symptoms of sepsis Elevated BUN and creatinine Persistent nausea and vomiting Signs and symptoms of uremia High-grade obstruction Hyperkalemia 25

26 26

27 Aim of study Wheather improvement of kidney function after drainage of the obstructed kidney are depend on parenchymal thickness and hemoglobin level 27

28 Methods Prospective study 124 patients with bilateral (or unilat in solitary kidney) obstructive uropathy underwent percutaneous nephrostomy BUN, serum creatinin and Hb measured 28

29 Methods Kidney perenchym thickness measured by Pie Medical scanner 200 ultrasound Patients were stratified into Hb <8 mg/dl (Hg 1) and Hb 8 mg/dl (Hb 2) groups; renal parenchym thickness into <0.5 cm (K1) and 0.5 cm (K2) groups 29

30 Results n = 124 pts Creatinine (mg/dl) at H 14: Hb ± 1.1 Hb ± 1.1 (p < 0.01) K1 2.7 ± 1.0 K2 1.7 ± 0.6 (p < 0.01) 30

31 Conclusion Haemoglobin level and renal parenchymal thickness are good prognostic factors for renal function recovery after percutaneous nephrostomy in obstructive uropathy patients 31

32 SUMMARY 1. Urinary tract obstruction tubular pressure changes, renal blood flow, and glomerular filtration rate affecting the excretion function and renal homeostasis irreversible renal impaired 1. Several substances are thought to play a role in the apoptosis tubulular fibrosis and atrophy ==> tubulointerstitial fibrosis ==> The mechanism of the development of CRF 32

33 SUMMARY 3. There are several differences between BUO and UUO ==> hemodynamic changes and some factors that might affect GFR 4. A number of vasoactive substances are thought to play a role in the changes in RBF and GFR occurring with both models of obstruction. 33

34 Thank You 34

35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 49

50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64 64

65 65

66 66

67 67

68 68

69 69

70 70

71 71

72 72

73 73

74 74

75 75

76 76

77 77

78 78

79 79

80 80

81 81

82 82

83 83

84 84

85 85

86 86

87 87

88 88