Ureteral obstruction Flashcards

1
Q

Name ddx for proximal hydronephrosis?

A

Acquired:
Extrinsic: ureteral stone, peripelvic cyst or mass
Intrinsic: benign fibroepithelial polyp, urothelial malignancy, post-inflammatory or post-operative scarring or ischemia

Congenital: retrocaval ureter (S shaped RGP), aperistaltic ureteral segment, mucosal kink/valve/adhesion

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2
Q

Describe dismembered ureteroplasty with transposition of ureter:

A
  1. Foley
  2. Lateral decubitus left side down (if doing retrocaval ureter)
  3. Port placement like kidney
  4. Transpertioneal, mobilize bowel
  5. mobilize proximal ureter/UPJ
  6. Divide ureter above and below IVC, leaving enough redundancy to perform UU
  7. Reconstruct ureter anterior to IVC, spatulate +/- graft, anastomosis watertight, 4-0 Vicryl, stent
  8. Drain
  9. Close
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3
Q

Pathophysiology of retrocaval ureter?

A

failure of supra-cardinal vein to develop into IVC below kidney possibly due to persistent of sub-cardinal vein or persistent of posterior cardinal vein as infrarenal IVC

1/1100, males, usually right, in 20s-30s

presenting sxs: abdominal/flank pain, recurrent UTI, HTN

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4
Q

What is differential of bilateral ureteral obstruction, not secondary to stones or retention?

A

lymphoma
metastatic dz (unknown primary including testis)
primary RP mass
RP fibrosis (proximal hydro, medial deviation, extrinsic compression of fibrotic plaque)

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5
Q

What lab studies are abnormal in retroperitoneal fibrosis? What is first step after b/l stents and monitoring for POD?

A

ESR

gamma globulin levels (IgG4)

First step: CT guided needle bx

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6
Q

Tx options for RP fibrosis?

A
  1. Glucocorticoids: most effective when labs abnormal, 20-60 mg daily x 6-8 weeks, then taper up to 24 mo, may be combined with other immunosuppressants, combine with H2 blockers and Ca
  2. Tamoxifen: anti-estrogen, in desmoid tumors and invasive fibrous tissue, 20 mg daily x 12 mo
  3. If no improvement, resection, ureterolysis, if not possible can do reimplant, psoas hitch, boari flap, ileal interposition, or autotxp
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7
Q

Causes of RP fibrosis?

A
  1. Drugs: beta blockers, methyldopa, hydralazine, ergotamine alkaloids (LSD, methysergide), haloperidol, amphetamines, phenacetin, risperidone
  2. Infection: syphilis, Tb, gonorrhea, chronic UTI
  3. Chemicals: asbestos, talcum powder, avitene
  4. Malignancy: primary, chancroid, mets RP tumors
  5. Idiopathic
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8
Q

What is a surgical approach for b/l RP fibrosis with extrinsic compression of ureter?

A

bilateral ureterolysis

Robotic/lap or open

take biopsies with intraop frozen (demoplastic fibrous tissue)

ID ureter over iliac (usually less involved there)

incise posterior peritoneum

DISSECTION BEGINS over distal, non-dilated ureter and proceed proximally (avoid injury to dilated segment)

may consider omental wrap (mobilize omentum from transverse colon (divide and ligate short gastric vessels to swing omentum laterally)

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9
Q

Describe and endopyelotomy:

A

Antegrade or retrograde

Make longitudinal incision posteriolaterally at UPJ (avoid injury of possible crossing vessel) until you see peri-ureteral fat. Leave stent. Use safety wire across UPJ.

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10
Q

What are options for failed pyeloplasty and persistent UPJO?

A
  1. Salvage endopyelotomy
  2. Re-do pyeloplasty
  3. Ureterocalicostomy (if renal pelvis small and primary anastomosis not possible
  4. Ileal ureter (long stricture, must have decent GFR, Cr < 2)
  5. Autotransplant (if no other tx feasible)
  6. Nephrectomy (< 10% function, normal contralateral, if further repair extremely complicated, short life expectancy, comorbid conditions)
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11
Q

Describe ureterocalicostomy:

A
  1. Amputate lower pole of kidney
  2. Mobilize lower poly calyx
  3. Excise strictured ureter
  4. Spatulate ureter
  5. Obtain watertight tension free anastomosis of ureter and calyx
  6. Insert stent
  7. Wrap omentum, peritoneum, or peri-renal fat around anastomosis
  8. Place drain
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12
Q

What does Tb look like in ureter? How do you treat?

A

Urine culture for AFB: + mycobacterium Tb

hydronephrosis with calcification along the ureter/narrowing/stricture

also assess kidney (tends to have trickle down effect, tend to have infundibular stenosis and papillary necrosis)

Treatment: PCN or stent, treat Tb (INH + Pyridoxine, Rifampin, Pyrazinamide? (resistance), Ethambutol)

*meds have high urinary concentrations

After period of recovery consider URS + bx (fibrosis)

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13
Q

What are options for mgmt of distal ureteral strictures?

A
  1. Endourologic: stent, balloon dilation (antegrade/retrograde), endoureterotomy
  2. Surgical recon: UU (short defect upper/mid) , transUU, reimplant (best for distal +/- Boari and/or psoas hitch), ileal ureter (very long, other failures, keep in mind metabolic concerns), autotxp

IMPORTANT: if considering Boari or Psoas Hitch must evaluate bladder fxn and capacity, BOO, and NGB

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14
Q

Describe a ureteroneocystostomy (reimplant) with Boari flap:

A
  1. Foley
  2. Access(open or robot, supine)
  3. ID ureter crossing iliac vessels
  4. Preserve adventitia to max post-op blood supply
  5. can perform flex URS to help ID distal extent of stricture
  6. transect at level of obstruction, mobilize proximally
  7. Perform reimplant only if tension-free, if not boari +/- psoas hitch
  8. Divide contralateral blader pedicle for improved mobility
  9. Posterolateral bladder flap outlined based on identification of ipsilateral superior vesicle artery
  10. Distal end of flap should be pexed to psoas minor tendon or psoas major muscle with absorbable suture
  11. Distal ureter should be spatulated and anastomosis performed
  12. Bladder flap tubularized and closed
  13. Leave JJ stent in place prior to closing flap
  14. Place drain
  15. Leave Foley cath in place
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