Upper Urinary Tract Obstruction

Pathophysiology of Obstruction

Unilateral ureteral obstruction (UUO) — triphasic

Phase	Timing	Renal blood flow	Ureteral pressure	GFR
1	1–2 h	↑	↑	Stable
2	2–5 h	↓	↑	↓
3	> 5 h	↓	↓	↓

Bilateral ureteral obstruction (BUO) — biphasic

Phase	Timing	Renal blood flow	Ureteral pressure	GFR
1	< 1 h	Mildly ↑	↑↑↑	↓
2a	1–5 h	↓	↑	↓
2b	> 5 h	↓↓↓	↑ (sustained to 24 h)	↓

• The initial vascular response to complete ureteral obstruction is preglomerular vasodilatation.
• Efferent arteriolar constriction is a second-phase event in bilateral obstruction only — it does not occur in unilateral obstruction.
• The first renal function parameter impaired by ureteral obstruction is water reabsorption.
• A JJ stent left > 4 weeks after chronic obstruction decreases ureteral contractility and contributes to VUR.

Post-Obstructive Diuresis (POD)

Urine output > 200 mL/hr for 2 consecutive hours, or > 3 L over 24 hours, following relief of urinary tract obstruction.

Type	Driver
Physiologic (most common)	Volume overload (excess fluid, ANP) and solute accumulation (Na, urea)
Iatrogenic	Excessive re-hydration; glucose-containing fluid causing an osmotic diuresis
Pathologic	Tubular dysfunction — see below

Pathologic POD — three mechanisms

• Loss of active Na reabsorption in the thin ascending limb ("salt-wasting nephropathy") — mediated by ANP and downregulated Na transporters (ENaC, Na/K/ATPase, Na/K/2Cl).
• Loss of urea backflux from the inner medullary collecting duct ("medullary washout") — the medullary counter-current gradient is lost.
• Decreased water reabsorption in the PCT, thick ascending limb and collecting duct — a poor response to ADH (nephrogenic DI) from downregulation of AQP-2 channels.

Pathologic POD occurs almost only in patients with:

• Signs of fluid overload — edema, CHF, hypertension
• Abnormal renal function
• Abnormal electrolytes

Management

• Monitor vitals and mental status.
• Hourly urine output on a strict input/output chart.
• Replace approximately 50–75% of the urine output with 0.45% NS. Replace orally if mental status is stable and the patient can tolerate it. Over-replacement perpetuates the diuresis.
• Serum Na, K, Mg, urea, creatinine, PO4 — frequently at first, then widen the interval.
• Urine Na, K and osmolality to separate a urea from a salt diuresis.
• Renal ultrasound.
• Daily weight.

Urea diuresis is usually self-limiting; a salt diuresis can convert to a pathologic POD.

Infundibular Stricture

Causes

• Congenital
• Acquired — post-PCNL (~2%)
• Inflammation
• Crossing vessel — Fraley syndrome

Indications for management

• Preserve renal function — progressive deterioration
• Relieve symptoms — pain, infections, stones

Treatment options

• Nephrostomy or DJ stent
• Balloon dilatation
• Endoscopic incision → incise lateral
  • Avoid incising the anterior or posterior wall — blood vessels run there
  • Depth of cut 2–3 mm
  • Success 60–80%
• Partial nephrectomy → if other methods fail
• Nephrectomy → if non-functioning kidney

Ureteropelvic Junction Obstruction (UPJO)

Causes

Category	Mechanism	Detail
Congenital	Intrinsic	Aperistaltic segment — absent/interrupted circular muscle, with the normal spiral musculature replaced by abnormal longitudinal muscle bundles; true congenital stricture (excess collagen); congenital kinks or valvular mucosal folds. Seen in infants
Congenital	Extrinsic	Crossing vessels — usually a lower-pole vessel, truly aberrant only if it crosses the ureter posteriorly; external bands or adhesions; persistent fetal convolutions. Seen in children & adolescence
Acquired	—	Stones, urothelial malignancy, post-operative/iatrogenic scarring or ischemia, inflammatory stricture, benign upper ureteral fibroepithelial polyp, VUR

Presentation

• Hydronephrosis on perinatal imaging — the commonest modern presentation
• Flank mass in a neonate
• Found during work-up for azotemia
• Intermittent abdominal or flank pain — Dietl's crisis
• Hematuria
• Recurrent UTI / pyelonephritis
• Hypertension

Investigation

• Goal: determine the anatomy and the functional significance of the obstruction
• Labs, urinalysis & culture
• Imaging:
  • Pediatric → US — ballooning of the renal pelvis
  • Adult → CT urography
• MAG3 — the preferred functional modality (function / drainage)
• RGP (retrograde pyelogram)

Laparoscopic and robotic pyeloplasty have reduced the need for preoperative assessment of crossing vessels — they can be dealt with at the time of pyeloplasty.

Whitaker test — if RGP cannot be done, place a nephrostomy and perform it through that. The renal pelvis is perfused continuously at 10 mL/min with saline or dilute contrast while the bladder is drained by an indwelling catheter (so intravesical pressure is not transmitted).

Indications for intervention — Pediatric

• Symptoms / infection
• Progressive hydronephrosis
• Split function < 40%
• Stones
• Consider nephrectomy in pediatrics if function < 10%

Indications for intervention — Adult

• Symptoms & impaired renal function, or progressive impairment, or stones, or infection
• Nephrectomy if function < 20% and symptomatic
• If in doubt → place a DJ stent or nephrostomy, then repeat assessment. In kidneys functioning at only 15–20%, temporize this way and repeat functional imaging later rather than proceeding straight to nephrectomy

All-comers checklist — BRUSSSHH:

• Bilateral disease
• Renal function impairment — overall < 40% with poor washout, or declining on serial studies
• UTIs
• Solitary kidney
• Symptoms
• Stones
• Hydronephrosis increasing on serial studies
• Hypertension (causal)

Treatment options — success rates

Option	Success
Nephrostomy or stent	—
Balloon dilatation	71%
Endopyelotomy	81%
Pyeloplasty	90%
Nephrectomy	if non-functioning & symptomatic

Cautions / contraindications to dismembered pyeloplasty

• (1) Small, inaccessible intrarenal pelvis
• (2) Lengthy or multiple proximal ureteric strictures (a diseased segment > 2 cm)

Flap procedures — when to choose which:

Procedure	Best suited to	Contraindications
Foley Y-V plasty	UPJO from a highly inserted ureter. Largely replaced by dismembered pyeloplasty	Crossing vessel; redundant renal pelvis
Culp-DeWeerd spiral flap	Large, readily accessible extrarenal pelvis with the ureter already inserting in a dependent, oblique position. Preferred over dismembered when there is a long segment of proximal ureteral narrowing or stricture	Crossing vessel; small intrarenal pelvis
Scardino-Prince vertical flap	Only if the ureter inserts dependently at the medial margin of a large, square "box-shaped" extrarenal pelvis. Now generally replaced by dismembered pyeloplasty. May be preferred for long proximal narrowing, but cannot make as long a flap as the spiral flap	—

Indications for ureterocalicostomy:

1. UPJO with a small intrarenal pelvis
2. Long proximal ureteric defect
3. Associated rotational anomalies (e.g. horseshoe kidney) — provides completely dependent drainage
4. Salvage after a failed dismembered pyeloplasty

Pyeloplasty

Goals of the repair:

1. Widely patent, tension-free, watertight anastomosis
2. Funnel-shaped transition between pelvis and ureter
3. Ureter in a position of dependent drainage

Indications for pre-operative decompression of UPJO:

• Infection with UPJO
• Renal failure from bilateral UPJO, or UPJO in a solitary kidney
• Severe, unrelenting pain

Advantages of dismembered (Anderson-Hynes) pyeloplasty:

• Allows reduction of a redundant pelvis
• Allows straightening of a tortuous proximal ureter
• Usable regardless of whether the ureter inserts high or low
• The only technique that completely excises an anatomically/functionally abnormal UPJ
• Allows transposition of the UPJ to relieve crossing-vessel compression

Post-operative care:

• Pre-operative antibiotic coverage maintained
• Foley removed at 24–36 h
• Surgical drain removed before discharge if output is negligible. If drainage increases after the Foley comes out, re-insert the Foley for 7 days — this eliminates reflux along the stent and reduces extravasation
• Stent removed at 4–6 weeks; ultrasound at 6 weeks
• Renal scan at 6 months to 1 year
• Imaging again at 3 years

After an open repair specifically: Penrose drain out at 24–48 h (a suction drain prolongs a leak); antegrade nephrostogram at 7–10 days if a nephrostomy was left in situ; percutaneous drain if a urinoma forms; imaging 4 weeks after the stent or nephrostomy is removed.

Complications of laparoscopic pyeloplasty:

Colon injury · renal vessel injury · hemorrhage · urinoma · pancreatic injury · ileus · pneumonia · thrombophlebitis · recurrent obstruction (~5%)

30% of failures occur beyond 2 years — hence follow-up to 3 years post-op.

Options after a failed pyeloplasty:

• Endopyelotomy
• Salvage open pyeloplasty
• A flap or dismembered technique not used at the first attempt
• Ureterocalicostomy
• Ileal ureter transposition
• Autotransplantation + Boari flap pyelovesicostomy
• Nephrectomy

Endopyelotomy — contraindications by approach

Hot-wire balloon endopyelotomy:

• Long segment of obstruction > 2 cm
• Presence of stones
• Crossing vessel
• Relative: significant hydronephrosis → an antegrade approach is better

Percutaneous endopyelotomy:

• Long segment of obstruction > 2 cm
• Active infection
• Untreated coagulopathy
• Crossing vessel — relative only

Percutaneous endopyelotomy is indicated mainly when UPJO coexists with stones. When both are present:

• Treat upper tract stones before the endopyelotomy, to avoid migration or extrusion of fragments.
• Make sure the UPJO is not simply edema from the stone disease — if in doubt, treat the stones first, leave a nephrostomy, and radiographically reassess the UPJ.
• Lower-pole stones with UPJO can be treated concurrently — the obstruction is not from edema in that case.

The advantage of the ureteroscopic approach is direct visualization of the UPJ and assurance of a properly situated, full-thickness incision, with no need for percutaneous access.

Endopyelotomy — technique & failure

• Full-thickness lateral incision from the lateral ureteral lumen out to the periureteric fat
• Most likely to fail if:
  • Stenosis > 2 cm
  • Crossing vessels
  • Ipsilateral kidney function loss (< 25% function)
  • Massive hydronephrosis
• Avoid strenuous activity for 8–10 days afterwards.
• Ideal stent size, stent duration and radiographic follow-up after endopyelotomy remain unclear.
• The fluoroscopically guided cautery wire balloon has a high complication rate; if used, keep the JJ stent 4–6 weeks post-operatively.

Ureteric Stricture

Etiology

• Idiopathic
• Acquired:
  • Malignancy
  • Radiation
  • Endometriosis / retroperitoneal fibrosis
  • Renal ablation injury
  • Impacted ureteral stone
  • Ischemia or trauma from surgical dissection
  • Endoscopic instrumentation
  • Infection — e.g. TB, schistosomiasis

Work-up

• Goal: determine whether the stricture impairs renal function, produces symptoms, or arises from malignancy
• History and physical — assess risk factors
• Imaging — assess location, nature and length: IVP · retrograde pyelogram · CT urography
• Renal scan — endourologic therapy needs ≥ 25% function to have a reasonable chance of success
• Bloodwork — routine, plus renal function
• Ureteroscopy ± biopsy ± barbotage — perform if the etiology of the stricture is uncertain

Management

• Stent or nephrostomy
• Balloon dilatation
• Endoureterotomy
• Surgical repair
• Nephrectomy → symptomatic, non-functioning

Endourologic management

Contraindicated if there is active infection, or the stricture is > 2 cm (stent length excluded).

• Stent — for acute decompression. A chronic stent is for a patient with poor prognosis who is not a repair candidate; it is not a good chronic option for extrinsic causes.
• Balloon dilatation
• Endoureterotomy — follow for up to 2 years with diuretic renography.

Optimal therapy for a benign ureteral stricture — assess length and renal function:

Length / function	Management
< 2 cm and > 20% function	Endoscopic incision — direction by level, see Where to Cut below
> 2 cm, moiety > 20%	Open or laparoscopic repair
> 2 cm, moiety < 20%	Laparoscopic nephrectomy

Consider balloon dilatation if the kidney is a transplant on immunosuppression. Pediatric patients and selected patients with renal insufficiency may warrant repair rather than nephrectomy.

Balloon dilatation

• Diameter 12F–30F, time 30 s to 10 min
• Place a stent afterwards
• Failure rate increases if:
  • Ischemic etiology of the stricture
  • Length > 2 cm
  • Located in the mid ureter
  • Kidney function < 25%

Open Surgical Repair

• Ureteroureterostomy → short upper or mid ureteric strictures
• Ureteroneocystostomy → distal ureteric strictures (3–4 cm), ± psoas hitch ± Boari flap
• Transureteroureterostomy (TUU)
• Ileal ureter
• Renal descensus
• Autotransplantation

There is no role for ureteroureterostomy in the distal ureter.

Technique	Ureteral defect length
Ureteroureterostomy	2–3 cm
Ureteroneocystostomy	4–5 cm
Psoas hitch	6–10 cm
Boari flap	10–15 cm
Renal descensus	5–8 cm

Psoas hitch

• For a defect in the distal one-third of the ureter — > 85% success
• Contraindications: small contracted bladder with limited mobility · neurogenic bladder · injury above the pelvic brim · bladder outlet obstruction
• Evaluate the bladder pre-operatively — treat BOO and neurogenic bladder first, consider urodynamics
• Free the peritoneal attachments and divide the vas deferens / round ligament; for more mobility, divide the contralateral superior vesical artery
• Secure the ipsilateral bladder dome to the psoas minor tendon / psoas major muscle — watch for the genitofemoral and femoral nerves
• Insert the ureter in a superolateral position on the bladder
• Advantages: technically simpler, lower risk of vascular compromise and of voiding difficulty

Boari flap

• For distal, mid and some proximal ureteric defects — bridges a 10–15 cm defect, and can sometimes reach the renal pelvis, especially on the right
• Contraindications: small contracted bladder with limited mobility · neurogenic bladder · bladder outlet obstruction
• Evaluate the bladder pre-operatively — treat BOO and neurogenic bladder first, consider urodynamics
• Free the peritoneal attachments, divide the umbilical ligaments, ligate the contralateral superior vesical artery
• Raise a posterolateral bladder flap based on the ipsilateral superior vesical artery, continuing onto the anterior bladder wall
• Base ≥ 4 cm, tip ≥ 3 cm; length sufficient to cover the defect; length-to-base ratio must never exceed 3:1

Transureteroureterostomy (TUU)

• For mid to lower ureteric defects where the length is insufficient to reach the bladder
• Absolute contraindications: donor ureter too short to reach the contralateral side · diseased recipient ureter
• Relative contraindications: stone disease · retroperitoneal fibrosis · urothelial carcinoma · chronic pyelonephritis · abdomino-pelvic radiation
• VUR must be corrected at the time of TUU — get a VCUG before proceeding
• Mobilize the colon medially on both sides, expose the recipient ureter ~5 cm proximal to the level of the divided ureter, and tunnel under the sigmoid mesentery, proximal to the IMA

Ileal ureteral substitution

• For ureteral defects too long for any other method, with a bladder unsuitable for reconstruction
• The appendix and fallopian tube are unreliable substitutes
• Contraindications: renal insufficiency (creatinine > 2 mg/dL) · bladder dysfunction · bladder outlet obstruction · inflammatory bowel disease · radiation enteritis

Options for a long proximal ureteric stricture or defect

1. Culp-DeWeerd spiral flap pyeloplasty
2. Scardino-Prince vertical flap pyeloplasty
3. Davis intubated ureterotomy
4. Ureterocalicostomy
5. Boari flap + psoas hitch
6. Ileal interposition
7. Renal descensus + ureteroureterostomy
8. Renal autotransplantation
9. Chronic stent changes
10. Nephrectomy

Principles of ureteric anastomosis

• Excise devitalized tissue — especially in gunshot wounds, where the tissue margins are burned
• Limit handling of ureteric tissue
• Preserve the adventitia to maximize ureteral blood supply
• Spatulate widely — if the ureter is dilated, transect obliquely to match the caliber of the lumen
• Watertight, tension-free anastomosis
• Stent the ureter
• Cover with retroperitoneal fat or omentum where possible
• Place a surgical drain

Endoureterotomy & Endopyelotomy — Where to Cut

Location	Incision direction
UPJ	Lateral
Abdominal ureter	Lateral / posterolateral
Over common iliac vessels	Anterior
Pelvic ureter	Anteromedial
UVJ	12 o'clock

Special situations

• Transplant kidney ureteral stricture: do NOT excise the stenosis — ischemia will develop. Initial management is endoscopic.
• Uretero-intestinal anastomosis (ileal conduit): stricture is more common on the left ureter due to extensive mobilization — kinking occurs as the left ureter courses under the IMA.
• Endoscopic incision of a LEFT ureteroenteric stricture in an ileal conduit risks hemorrhage — the sigmoid mesentery can lie in close proximity. Combined with the low endoscopic success rates on that side, these patients may be best treated with definitive repair from the outset.

Uretero-intestinal stricture — management algorithm

Long-term patency after a minimally invasive procedure for a ureteroenteric stricture is only about 50%, but these approaches are still used as the initial intervention, with operative management reserved for endourologic failure.

Stricture	Sub-condition	Management
< 2 cm, > 20% function	Right ureter	Endoscopic incision
< 2 cm, > 20% function	Left ureter	Consider formal repair
> 2 cm	> 20% function	Consider formal repair
> 2 cm	< 20% function	Nephrectomy or observation

Consider balloon dilatation instead if the kidney is a transplant on immunosuppression.

• Within the < 2 cm group, a length > 1 cm (success 6% vs 50%) and a left-sided stricture (19% vs 41%) each predict endourologic failure — favor primary formal repair on the left.

Retrocaval (Circumcaval) Ureter

• Embryology: persistence of the posterior cardinal as the IVC — ureter passes behind the IVC. Almost always right-sided. (preureteral vena cava > persistence of the subcardinal vein)
• Classic imaging: ureter loops medially behind the IVC — "reverse-J" / fish-hook appearance on IVU / CT urography.
• A retrocaval ureter is not always associated with ureteral obstruction. Diagnosis is usually confirmed by CT.
• Type 1 (more common) — the S-shaped "fish-hook" ureter; associated with a greater degree of hydronephrosis, with the point of obstruction lateral to the lateral border of the IVC. Type 2 — the sickle-shaped ureter, with less obstruction.
• Treat only if there is functionally significant obstruction causing pain or renal function deterioration. The standard repair is an open pyelopyelostomy: place a JJ stent, identify and dissect the ureter, dilated renal pelvis and IVC, transect the dilated pelvis, transpose the ureter anterior to the IVC, then re-anastomose circumferentially with absorbable sutures, tension-free and watertight. A surgical drain and internal ureteral stent are typically used. Open, laparoscopic and robotic approaches are all described.

Obstructed (Primary) Megaureter

• Definition: ureter > 7 mm distal diameter. Primary obstructive megaureter = aperistaltic juxtavesical segment (no reflux, no distal obstruction by stone/valve).
• More common in males, more often left-sided; up to ~25% bilateral.
• Work-up: US, VCUG (exclude reflux), MAG3 (function & drainage).
• Management:
  • Most resolve spontaneously → observe with serial US / renography.
  • Surgery if: declining function, breakthrough infections, worsening obstruction, or symptoms.
  • Repair = excision of aperistaltic segment + ureteral tapering / plication + reimplantation. In infants too small to reimplant, temporize with a stent or cutaneous ureterostomy.

Retroperitoneal Fibrosis (RPF / Ormond Disease)

• Fibro-inflammatory plaque centered on the distal aorta at L4–L5, encasing the aorta, IVC, and ureters → medial deviation + ureteric obstruction (classically the mid-ureter).
• Symptoms and signs are nonspecific. Labs may show elevated ESR and CRP, moderate leukocytosis, anemia, and variable renal insufficiency with electrolyte abnormalities.
• Idiopathic (70%) — associated with chronic aortitis. Identifiable cause (30%) — most commonly drugs: methysergide and other ergot alkaloids, also beta-blockers and phenacetin (the mechanism of drug-induced RPF is unknown); plus malignancy, radiation, infection, and IgG4-related disease.
• Imaging: CT/MRI shows a confluent peri-aortic plaque; the aorta is NOT lifted off the spine (vs. lymphoma). Rule out malignancy by biopsy before starting medical therapy.
• Management:
  • Relieve obstruction first → DJ stent or nephrostomy. After decompression, monitor closely for post-obstructive diuresis.
  • Idiopathic → first-line is corticosteroids or tamoxifen (a nonsteroidal antiestrogen). Mycophenolate mofetil, azathioprine or cyclophosphamide can be used as primary or salvage therapy but are given in combination with steroids — their stand-alone efficacy is unknown. IgG4-related disease responds to steroids.
  • Refractory / persistent obstruction → ureterolysis with intraperitoneal transposition or omental wrap. If ureterolysis fails → renal autotransplantation.
  • Stop the offending drug in secondary cases; treat the underlying cause.
  • After aortic/iliac graft surgery: grafts should be placed posterior to the ureter. Early ureteral obstruction from secondary RPF arising within six months of surgery can resolve with a four-week course of oral steroids.