Vesico Ureteral Junction Obstruction: Ardyansyah Can

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VESICO URETERAL

JUNCTION
OBSTRUCTION
ARDYANSYAH CAN
PATOLOGI OBSTRUKSI
Gross
◦ 48 jam: dilatasi collecting system, tumpulnya papil ginjal,
peningkatan berat ginjal
◦ 72 jam: edema parenkim
◦ 12 hari: dilatasi collecting system semakin nyata
◦ 21 – 28 hari: jaringan korteks dan medulla ginjal menipis
◦ Pada 6 minggu pasca obstruksi: ginjal yang terkena akan terlihat
gambarannya kistik, membesar namun lebih ringan jika
dibandingkan dengan ginjal normal
Mikroskopik
◦ Dilatasi tubulus
◦ Infiltrasi sel inflamasi - penebalan interstitial space - fibrosis
◦ Fibrosis tubulointerstisial yang progresif
◦ Apoptosis sel tubulus ginjal
PATOLOGI OBSTRUKSI
DAMPAK KLINIS
◦ Hipertensi
◦ Compensatory contralateral renal growth
 cellular hypertrophy
◦ Post-obstructive diuresis
◦ UO ≥ 200 ml/jam
◦ Bilateral  tidak ada ginjal yang
mengkompensasi  ANP ↑
◦ Unilateral  kompensasi oleh ginjal
kontralateral
TERMINOLOGY
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

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 a description = dilatation
Hydronephrosis does not mean always obstruction
Can be:
◦ Obstruction
◦ VUR
◦ Mechanical problem
◦ Functional problem
Obstructive urophaty
Can we wait?
How long can we wait?
Do we compromise anything if we wait? Which kidney will eventually deteriorate?
Does it harm to perform surgery if not necessary?
What can we do?
How can we do?
VESICO URTERIC JUNCTION
OBSTRUCTION (VUJO)
The ureterovesical junction is located
where the ureter (the tube that drains
urine from the kidney) meets the
bladder.
Ureterovesical junction (UVJ)
obstruction refers to a blockage to this
area.
The obstruction impedes the flow of
urine down to the bladder, causing the
urine to back up into and dilate the
ureters and kidney (megaureter and 
hydronephrosis).
McAninch, J. W., & Lue, T. F. (2020). Smith & Tanagho’s general urology. https://accessmedicine.mhmedical.com/book.aspx?bookid=2840
EPIDEMIOLOGY
Obstruction at the ureterovesical junction is 4 times more common in
boys than in girls. It may be bilateral and is usually asymmetric. The
left ureter is slightly more often involved than the right.
Currently, most cases are discovered on prenatal sonography.
 pathognomonic configuration of a dilated distal ureter,
 a less dilated proximal ureter,
 a relatively normal-appearing renal pelvis, and
 calyces blunted out of proportion to the renal pelvis
McAninch, J. W., & Lue, T. F. (2020). Smith & Tanagho’s general urology. https://accessmedicine.mhmedical.com/book.aspx?bookid=2840
McAninch, J. W., & Lue, T. F. (2020). Smith & Tanagho’s general urology. https://accessmedicine.mhmedical.com/book.aspx?bookid=2840
SIGN AND SYMPTOM
Prenatal USG  UVJ obstruction may be identified before any
symptoms are present.
Older children typically have:
- Back or Flank Pain
- Nausea and vomiting related to the pain
- UTI (often with fever)

European Association of Urology. (2021) EAU Guideline on Pediatric Urology.


Diagnostic Evaluation Antenatal Ultrasound

16th and 18th weeks of pregnancy kidneys are visualised


28th week of pregnancy most sensitive time foetal urinary tract evaluation
If dilatation is detected, US should focus on:
laterality, severity of dilatation, and echogenicity of the kidneys;
hydronephrosis or hydro-ureteronephrosis;
bladder volume and bladder emptying;
sex of the child;
amniotic fluid volume
European Association of Urology. (2021) EAU Guideline on Pediatric Urology.
Diagnostic Evaluation
Postnatal Ultrasound

Ultrasound should assess


the anteroposterior diameter of the renal pelvis,
calyceal dilatation,
kidney size,
thickness of the parenchyma,
cortical echogenicity,
ureters, bladder wall and residual urine

European Association of Urology. (2021) EAU Guideline on Pediatric Urology.


Diagnostic Evaluation
Ultrasound: AP diameter
= most valuable information Ultrasound – hydronephrosis with
normal ureter and bladder
= most predictive factor
AP diameter risk of surgery
< 15 mm 2% minimal
<15-20 mm 7% moderate
<20-30 mm 29 % severe
<30-40 mm 61 %
<40-50 mm 67 %
> 50 mm 100 %

Desai, Dhillon, Duffi: Progress in Paediatric Urology Vol 3, 1999


UPJ obst

RENOGRAPHY
MAG-3  diff fn, diuresis renography
DTPA  diff fn, diuresis renography (more
background activity in infants)
DMSA  diff fn, renal scarring
Glucoheptonate  diff fn, perfusion, renal scarring
(images not very sharp; substitute if DMSA
unavailable)

Diuretic renogram – delayed visualization of kidney,


delayed drainage from the renal pelvis
UPJ obst

DIURETIC RENOGRAM
IV hydration; catheter in bladder
Differential function : calculated from uptake in first 2 minutes
Lasix  give 1 mg/kg at 20 to 30 minutes; collecting system should be
full

T ½ < 15 minutes normal


T ½ > 20 minutes abnormal, but may
not indicate of obstruction
UPJ obst

Diff fn T½ management
(%) (minutes)

> 45 < 15 Repeat US in 3 months

40 – 45 15 – 20 Probably save to follow with repeat US in 3


months

< 40 > 20 Pyeloplasty

< 10 Percutaneous nephrostomy and reassess


diff function in 2 -4 weeks
MANAGEMENT
Pre-natal
◦ Konseling dan edukasi pada orangtua, serta menginfokan pada dokter
obstetric dan pediatrik untuk kemungkinan outcome dari kehamilan, salah
satunya pada obstruksi bilateral yang menyebabkan oligohidramnion 
pulmonary hypoplasia

European Association of Urology. (2021) EAU Guideline on Pediatric Urology.


Post-natal
Remisi spontan dapat dijumpai hingga 85% kasus megaureter,
sehingga tatalaksana non operatif merupakan terapi yang lebih
banyak dilakukan pada saat ini.
Tatalaksana  antibiotik profilaksis dosis rendah pada tahun
pertama untuk pencegahan ISK.
Pasien dengan dilatasi ureter > 10 mm  intervensi bedah.
COMPLICATION
Common complication:
 Megaureter
Hidronefrosis

Hodges SJ, Werle D, McLorie G, Atala A. Megaureter. ScientificWorldJournal. 2010 Apr 13;10:603-12. doi: 10.1100/tsw.2010.54. PMID: 20419273; PMCID: PMC5763690.
SURGICAL INDICATION
Indikasi bedah:
- Simptomatik
- Kegagalan terapi non operatif
SURGICAL MANAGEMENT
Traditionally  Open surgery, to excise the area of scarring
and re-connect the ureter to kidney
Minimally Invasive:
Endopyelotomy
Laparoscopic Pyeloplasty
SURGICAL MANAGEMENT
Prosedur reimplantasi ureter/ ureteroneosistostomi dapat dilakukan
secara intravesika, ekstravesika atau kombinasi keduanya
Kasus yang bilateral  teknik intravesika.
Ureter yang berkelok-kelok perlu diluruskan tanpa
mengorbankan vaskularisasi ureter.
Ureter yang sangat lebar  tapering atau plikasi  mekanisme
antirefluks.

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