PATOFISIOLOGI OBSTRUKSI URETER...
Transcript of PATOFISIOLOGI OBSTRUKSI URETER...
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Obstructive UropathyPATHOPHYSIOLOGIC CHANGES
UUO vs BUO
Arry Rodjani Urology Department
Ciptomangunkusumo Hospital Jakarta
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Obstructive uropathy refers to the functional or anatomic obstruction of urinary flow at any level of the urinary tract
INTRODUCTION
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
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INTRODUCTION
Urinary Tract Obstruction tubular pressure changes,
renal blood flow, and glomerular filtration rate affecting the
excretion function and renal homeostasis irreversible renal
impaired
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INCIDENS
Obstruction of the urinary tract may occur during
fetal development, childhood, or adulthood
In Indonesia mostly caused by stone in the urinary tract
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Posible causes of obstructive nephropathy
Congenital Polycystic kidney, renal cyst, aberrant vessel at ureteropelvic junction
Neoplastic Wilms’ tumor, renal cell ca, TCC of the renal pelvis, multiple myeloma
Inflamatory Tuberculosis
Metabolic Calculi
Miscellaneous Sloughed papillae, trauma, renal artery aneurism
Renal
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Posible causes of obstructive nephropathy
Congenital Stricture, ureterocele, ureterovesical reflux, ectopic kidney, retrocaval ureter, Prune-Belly syndrome
Neoplastic Primary carcinoma of ureter, metastatic carcinoma
Inflamatory Tuberculosis, abscess, ureteritis cystica, endometriosis
Miscellaneous Retroperitoneal fibrosis, pelvic lipomatosis, radiation therapy, lymphocele, trauma, urinoma, pregnancy
Ureter
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Posible causes of obstructive nephropathy
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 hyperplasiaNeurogenic bladder
Bladder and Urethra
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SYMPTOMS
Wide range symptoms, depend on:
1. Acute / chronic2. Unilateral / bilateral3. The cause of obstruction (extrinsic vs intrinsic)4. Complete obstruction / parsial obstruction5. Presence or absence of infection6. Compliance of collecting system
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Pathophysiologic changes
UUO vs BUO
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UNILATERAL URETERAL OBSTRUCTION (UUO)
1.Acute phase (1-2 hrs)2.Mid phase (2-5 hrs)3.Later phase (5-24 hrs)
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Triphasic relationship between ipsilateral renal blood flow and left ureteral pressure during 18 hours of left-sided occlusion
Pais V, In Walsh PC, Campbell’s Urology, WB Saunders 2007;37:1195-1126
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Summary of the functional changes during and following ureteral obstruction
Pais V, Pathophisiology of Urinary Tract Obstruction In Walsh PC, Campbell’s Urology, WB Saunders 2007;37:1195-1126
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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
BILATERAL URETERAL OBSTRUCTION (BUO)
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Summary of the functional changes during and following ureteral obstruction
Pais V, Pathophisiology of Urinary Tract Obstruction In Walsh PC, Campbell’s Urology, WB Saunders 2007;37:1195-1126
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Summary of the functional changes during and following ureteral obstruction
Pais V, In Walsh PC, Campbell’s Urology, WB Saunders 2007;37:1195-1126
Unilateral Bilateral or Solitary Kidney
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Unilateral Bilateral or Solitary Kidney
Pais V, In Walsh PC, Campbell’s Urology, WB Saunders 2007;37:1195-1126
Summary of the functional changes during and following ureteral obstruction
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Unilateral Bilateral or Solitary Kidney
Pais V, In Walsh PC, Campbell’s Urology, WB Saunders 2007;37:1195-1126
Summary of the functional changes during and following ureteral obstruction
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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
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GFR became normal after 1 week obstruction released.
Not all nephrons are functionally reversible hyperfiltration occur in normal nephrons as a compensatory mechanism GFR back to normal level
RENAL FUNCTIONAL CHANGES AFTER RELEASE OF OBSTRUCTION
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Summary of major pathways leading to tubulointerstitial fibrosis and tubular apoptosis as a consequence of ureteral obstruction
Pais V, In Walsh PC, Campbell’s Urology, WB Saunders 2007;37:1195-1126
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DIAGNOSIS
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MANAGEMENT
The management is performed to :
(a) relief pain
(b) recover or maintain renal function (c) avoid complication
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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
Indication to release obstruction
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Aim of study
Wheather improvement of kidney function after drainage of the obstructed kidney are depend on parenchymal thickness and hemoglobin level
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Methods
• Prospective study
• 124 patients with bilateral (or unilat in solitary kidney) obstructive uropathy underwent percutaneous nephrostomy
• BUN, serum creatinin and Hb measured
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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
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Results n = 124 pts
Creatinine (mg/dl) at H 14:
Hb 1 2.8 ± 1.1
Hb 2 1.8 ± 1.1 (p < 0.01)
K 1 2.7 ± 1.0
K 2 1.7 ± 0.6 (p < 0.01)
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Conclusion
Haemoglobin level and renal parenchymal thickness are good prognostic factors for renal function recovery after percutaneous nephrostomy in obstructive uropathy patients
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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
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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.
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Thank You
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