URINARY TRACT OBSTRUCTION OBSTRUCTIVE UROPATHY 1 Hydronephrosis is

URINARY TRACT OBSTRUCTION (OBSTRUCTIVE UROPATHY) 1

• Hydronephrosis is the term used to describe • dilation of the renal pelvis and calyces • associated with progressive atrophy of the kidney • due to obstruction to the outflow of urine 2

Hydonephrosis • • Partial / complete Sudden/progressive/intermittent Unilateral/bilateral Any level – pelvis/ureter/bladder/urethra 3

Hydonephrosis CAUSES • Intrinsic – intraluminal/intramural • Extrinsic • Congenital/acquired 4

Causes of Obstructive Uropathy 5

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Hydronephrosis: 7

Hydronephrosis: 8

Hydronephrosis Urolithiasis 9

Urolithiasis with hydronephrosis: 10

Urolithiasis /nephrolithiasis (renal calculi renal stones) 11

Kidney stones • Solid concretions ( crystal aggregations) of dissolved minerals in urine • found inside the kidneys or ureters. They vary in size from as small as a grain of sand to as large as a grapefruit 12

Urolithiasis • important in everyday urological practice. • average lifetime risk of stone formation is in the range of 5 -10%. • men > women (approx. 3: 1) • peak - 4 th & 5 th decades of life. • Recurrent stone formation is a common problem with all types of stones 13

Urolithiasis • males, • Renal colic, dull ache in loins • Urinary tract infection recurrent. • Factors affecting: Urine p. H, Infection, Metabolic low urine volume, decreased inhibitors 14

TYPES • COMPOSITION • PATHOGENESIS 15

Urolithiasis Infection Calcium oxalate (or phosphate) 75% Magnesium ammonium phosphate (struvite, or "triple phosphate") 12% Uric acid 6% Cystine 1% Other 6% 16

Renal stones • For precipitation of crystals in urine to occur, the urine must be "supersaturated" for the precipitating crystal. • Stone formation secondary to infection • obstruction related to a congenital malformation of the urinary tract (often present before the age of 5). 17

Stone Formation • The chemical composition of stones depends on the chemical imbalance in the urine. • Kidney stones form when there is a high level of mineral (s) in the urine; i. e. calcium (hypercalciuria), oxalate (hyperoxaluria), or uric acid (hyperuricosuria) 18

• Urine normally contains chemicals—citrate, magnesium, pyrophosphate—that prevent the formation of crystals • Low levels of these inhibitors can contribute to the formation of kidney stones. • Citrate is thought to be the most important • a lack of citrate in the urine • insufficient water in the kidneys to dissolve waste products. 19

• NIDUS – NUCLEATION (INITIATION) 100 ions • AGGREGATION (GROWTH) 20

HYPERCALCEMIA (1) increased secretion of PTH with subsequent bone resorption - hyperparathyroidism due to parathyroid tumors, - ectopic secretion of PTH-related protein by malignant tumors (2) destruction of bone tissue, • secondary to primary tumors of bone marrow (multiple myeloma, leukemia) • diffuse skeletal metastasis (breast cancer), • accelerated bone turnover (e. g. , Paget disease), • immobilization; 21

HYPERCALCEMIA (3) vitamin D–related disorders, • vit D intoxication, • sarcoidosis (in which macrophages activate a vit D precursor), • idiopathic hypercalcemia of infancy characterized by abnormal sensitivity to vit D; (4) renal failure, which causes retention of phosphate, leading to secondary hyperparathyroidism. 22

Calcium oxalate monohydrates • • Single/multiple Small-large Dirty yellow/brown Hard l. Calcium oxalate dihydrates Smooth/rough Jagged/spikes Cut surface-laminated 23

• Magnesium ammonium phosphate stones (12 -15% of cases) – Also called struvite, triple phosphate & infection stones – Associated with infections by urea splitting bacteria (Proteus) – Alkaline Urine – Stag-horn calculi – typically large – takes on shape of calyx 24

Struvite Stones • develops when a urinary tract infection affects the chemical balance (alkalinise) of the urine. • Bacteria in the urinary tract are capable of splitting urea into ammonia • decreases the acidity of the urine • enables bacteria to grow more quickly and promotes struvite stone development. . 25

Struvite • • • Single/multiple small-large Whitish yellow Soft friable STAGHORN Cut surface - laminated 26

• Struvite stones are more common in women. • The stones usually develop as jagged structures called "staghorns" and can grow to be quite large. 27

Staghorn Calculus: 28

Staghorn Calculus: 29

• Uric acid (urate) - 6% – Purine metabolism high turnover of protein metabolism (Gout, Leukemias & Lymphomas ) 30

Uric Acid Stones • If the acid level in the urine is high or too much acid is excreted, the uric acid may not dissolve and uric acid stones may form. • Uric acid stones form in acidic urine and often dissolve when the urine is alkalinized. • They are not visible on X-rays. • Patients with gout often develop these stones. 31

Uric acid • • • Single/multiple Brown Hard Round Smooth Cut surface - laminated 32

Cystine (1 -2%) – Genetic defects in reabsorption of amino acids 33

Cystine Stones • Cystine is an amino acid. • a rare, congenital condition that results in large amounts of cystine in the urine(called cystinuria) • causes cystine stones that are difficult to treat and requires life-long therapy. 34

Urolithiasis: 35

Clinical Manifestations • Acute obstruction of the urinary tract may cause renal colic • a form of severe abdominal pain often accompanied by nausea and vomiting • Onset is sudden, often during the night or in the early morning 36

HISTORY • • • Onset Fluid intake Diet Medications Urinary tract infections Family history 37

• A vast majority of stones will contain elements of calcium within them and therefore are easily seen on x-ray having the same density as bone. . 38

Diagnostic imaging Routine examination involves a plain abdominal film of the kidneys, ureters and bladder (KUB) At least 90% of all renal stones are radiopaque and therefore readily visible on a plain film of the abdomen 39

Type of stone ? ? 40

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Diagnostic imaging Excretory pyelography 42

Cystoscopy 43

Cystoscopy 44

Laboratory Investigations • Stone analysis: In every patient one stone should be analysed. • Blood analysis: Calcium Albumin Creatinine Urate • Urinalysis: Fasting morning spot urine sample Dip-stick test: p. H, Leucocytes/Bacteria Cystine test, Ca, P, citrate, urate 45