Advanced ovarian cancer: urinary tract resection as a part of cytoreductive surgery

Maximum surgical effort to minimize residual tumor following primary surgery has been shown to increase mean survival in patients with epithelial ovarian cancer. From September, 1983 to November, 1987, 22 patients underwent resection of the urinary tract as a part of cytoreductive surgery. Seven patients underwent partial cystectomy, four underwent partial cystectomy with ureteroneocystotomy, five patients underwent ureteroneocystotomy while an additional four patients underwent ureteroureteral anastomosis. One patient underwent primary transverse colon conduit while another underwent a similar procedure after developing urinary leakage. All anastomoses were protected with indwelling stents while the urinary bladder was drained with an indwelling Foley catheter for ten days. Both patients requiring conduits had undergone prior radiation therapy in addition to chemotherapy. Nine major and two minor complications occurred in seven patients. One patient died six weeks postoperatively after concurrent hepatic resection. Optimal cytoreduction was possible in 59% of the patients, and was associated with a mean survival of 15.2 months. Optimal cytoreduction including resection of the urinary tract was associated with longer survival and acceptable morbidity and it appears to be justified in patients with ovarian cancer.     

Laparoscopic management of ureteral endometriosis: our experience

STUDY OBJECTIVE: Ureteral endometriosis is rare, accounting for less than 0.3% of all endometriotic lesions. The aim of our study is to evaluate the prevalence of extrinsic ureteral endometriosis in women undergoing laparoscopic surgery for severe endometriosis and to suggest that laparoscopic ureterolysis represents a mandatory measure in all cases to avoid ureteral injury. METHODS: A retrospective analysis was performed of all cases of patients who underwent laparoscopic surgery for severe endometriosis at the departments of obstetrics and gynecology at CMCO-SIHCUS and Hautepierre Hospital, Strasbourg, from November 2004 through January 2006. MEASUREMENTS AND MAIN RESULTS: We recorded 54 patients with a mean age of 31 years and a mean body mass index of 21.9. Reported symptoms were dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), and infertility (74%). Five women presented with dysuria, frequency, recurrent urinary tract infections, and pain in the renal angle, and 2 patients had hydronephrosis. We observed 3 patients (5.6%) with ureteral stenosis, 35 (64.8%) with adenomyotic tissue surrounding the ureter without stenosis, and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right side in 31.6% cases, and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). In all patients, ureterolysis was performed. There was 1 case of ureteral injury during the procedure, 2 of transitory urinary retention, and 1 of uretero-vaginal fistula after surgery. During the first year of follow-up, the disease recurred in 4 patients, with no evidence of the disease in the urinary tract. CONCLUSION: Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathologic tissue is the management of choice. Resection of part of the ureter should be performed only in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage.     

Splenectomy as part of cytoreductive surgery in ovarian cancer

OBJECTIVE: Epithelial ovarian carcinoma with extensive upper abdominal disease may require splenectomy for optimal tumor cytoreduction. We describe patients who required splenectomy during tumor reduction procedures for primary or recurrent epithelial ovarian carcinoma. METHODS: Data were abstracted from records of 112 patients who underwent splenectomy as part of primary or secondary cytoreductive surgery. RESULTS: Of 112 patients, 66 had primary and 46 had secondary cytoreduction. Some patients also required bowel resection (50%), formal lymphadenectomy (31%), or urinary tract resection (5%). The most common indications for splenectomy were direct metastatic involvement (46%), facilitation of an en bloc resection of perisplenic disease (41%), and intraoperative trauma (13%). Histologically, 65% had hilar involvement; 52%, capsular involvement; and 16%, parenchymal metastases. Short-term complications included wound infections (7), pneumonias (5), thromboembolic events (9), and sepsis (5). Sepsis was associated with an anastomotic bowel leak in 1 patient, with fungal infections in 2 patients (1 pneumonia and 1 pelvic abscess), and with no identifiable infectious source in 2. Two patients required reoperation for bleeding: 1 for diffuse intraabdominal bleeding, including the splenic bed, and 1 for pelvic sidewall bleeding. The perioperative mortality rate at splenectomy was 5%: 3 from sepsis (1 anastomotic leak, 2 pneumonias), 2 from pulmonary embolism, and 1 for which the precise cause of death was not ascertainable. The primary cytoreduction group had a median survival of 1.8 years, with an estimated 2-year survival rate of 46%. The median survival in the secondary debulking group was 1.7 years, with an estimated 2-year survival of 42%. CONCLUSIONS: In patients with clinically significant upper abdominal disease, splenectomy as part of primary or secondary cytoreductive surgery is associated with modest morbidity and mortality. The risk-benefit ratio of aggressive surgical cytoreduction must be considered.     

Management of symptomatic pelvic lymphocyst after radical pelvic or pelvic and paraaortic lymphadenectomy for cervical and endometrial cancer

Pelvic and paraaortic lymph node dissection, as part of the staging surgery for cervical and endometrial carcinoma, interrupts the afferent lymphatics. The high acceptance by the community of gyn-oncologists was after finding that laparoscopic lymphadenectomy can be performed in the majority of patients and is associated with low complication rate. Incidence of lymphocele formation and incidence of severe complications associated with lymphocele, such as infection, deep venous thrombosis, or urinary tract occlusion, were retrospectively evaluated in the past years (01.2001–01.2007) after surgery. From January 2001 to January 2007, 226 women underwent surgery including pelvic or pelvic and paraaortic lymphadenectomy for primary gynecological pelvic malignancies, of which 68 (30%) patients had cervical cancer and 158 (60%) patients had endometrial cancer; all of them were retrospectively analyzed. Patients with symptoms such as pain in the pelvic area, lymphedema, or suspicious cyst in the pelvis were sent to our clinic for further evaluation. The identification was made by physical examination and confirmed by US or CT. Twenty three out of 226 (10.2%) patients were diagnosed to have symptomatic pelvic lymphocyst. Additionally, two of the 23 patients had lymphedema, another two patients had lymphocyst infection, one patient had deep venous thrombosis, and one patient had ureteral stenosis. A partial (ventral) resection of the lymphocyst was performed. Median duration of hospital stay was 12.5 days and median duration of drainage was 10 days. Laparoscopic lymphocyst resection and drainage was successful in 22 patients. In one patient, a re-laparoscopy was necessary because of a recurrent lymphocyst formation 6 months after the operation. The laparoscopic lymphocyst resection is a safe and effective procedure and was applied in all 23 patients successfully.     

妇科腹腔镜手术泌尿系损伤的临床分析

目的：探讨妇科腹腔镜手术发生泌尿系损伤的相关因素、诊断、治疗方法及预防措施。方法：回顾分析2002年1月至2012年12月北京大学人民医院妇科腹腔镜手术发生泌尿系损伤患者的临床资料。总结分析患者的疾病类型、手术方式、损伤特点、诊疗情况及预后等。结果：妇科腹腔镜手术共4773例,泌尿系损伤发生18例（0.38％）,其中8例发生于腹腔镜恶性肿瘤手术,8例发生于腹腔镜辅助阴式全子宫切除术（LAVH）,2例发生于腹腔镜附件手术。18例泌尿系损伤患者中5例有腹部手术史,有腹部手术史者的泌尿系损伤发生率高于无手术史者（P〈0.05）。18例泌尿系损伤患者中膀胱损伤4例,其中3例位于膀胱后壁,1例位于膀胱三角区;输尿管损伤14例,其中输尿管上段损伤2例,中段损伤10例,下段损伤2例;左侧输尿管损伤2例,右侧12例。术中发现损伤10例,其中4例膀胱损伤和6例输尿管损伤;术后发现8例,均为输尿管损伤,于术后1～10天发现,均经静脉肾盂造影确诊。11例经再次手术修补成功,7例放置输尿管支架6个月（3～12个月）保守治疗成功。结论：腹腔镜下恶性肿瘤手术、LAVH、有腹部手术史患者发生泌尿系损伤机率较高,输尿管损伤多于膀胱损伤。术者需高度警惕,术后严密观察,如发现泌尿道损伤,尽早请泌尿科医师共同决定治疗方法。     

妇科手术泌尿系统损伤42例临床分析

目的 探讨妇科手术泌尿系统损伤的临床特点和处理。方法 对1990年1月1日至2001年12月31日期间在北京协和医院妇科手术中发生的42例泌尿系统损伤的类型,时间,术后尿瘘的发生和诊治经过,进行回顾性分析。结果 在12849例妇科手术中,发生泌尿系统损伤42例,发生率为0.33%。其中,输尿管损伤11例,包括输尿管下段损伤5例,近膀胱入口段损伤4例和骨盆入口段损伤2例。发生率为0.09%;膀胱损伤31例,均发生于膀胱底部或后壁,发生率为0.24%,发现损伤的时间,术中32例（76%）,术后10例（24%）,尿瘘形成14例（33%）,其中10例经过尿,血和引流液电解质,肌酐和尿素氮含量的比较而明确尿瘘存在;9例行美蓝实验和（或）膀胱镜检查,其中4例经此项检查诊断为膀胱瘘;8例经静脉肾盂造影诊断为输尿管瘘;经过术中及时修补,置入输尿管双J管和（或）保留尿管开放治疗,41例治愈。结论 大部分妇科手术泌尿系统损伤,经及时诊断和处理,预后较好。     

CO2 Cystoscopy for Evaluation of Ureteral Patency

Gynecologic surgery is associated with various perioperative complications, especially urinary tract injuries. Intraoperative cystoscopy plays an important role in allowing assessment of the bladder to ensure the absence of injuries. Verification of the urinary jets from the ureters is a fundamental step that is not always easy to accomplish. Dyes are frequently used, but these are not always available and are associated with adverse effects. The present study aimed to demonstrate the use of CO₂ as a medium for distension during cystoscopy. A total of 47 patients underwent CO₂ cystoscopy after laparoscopic hysterectomy (n?=?26) or bladder endometriosis nodule resection (n?=?21). In all patients, the ureteral jets were readily identified, leaving no doubt as to their patency. The median interval between the onset of cystoscopy and the view of jetting from both ureteral ostia was 145 seconds (range, 80–300 seconds). All cystoscopies were normal, and no patient had any signs of accidental urinary tract injury in the follow-up period. Two patients experienced mild urinary tract infection. This cystoscopy technique using CO₂ is fast, easy, safe, and efficient. We recommend bladder distension with CO₂ as a reasonable alternative technique when cystoscopy is required during gynecologic procedures.     

Lower urinary tract reconstruction with ileum in the treatment of gynecologic malignancies

INTRODUCTION: Advanced or recurrent gynecologic malignancies can invade or obstruct the lower urinary tract. If extirpation is necessary for cytoreduction or repair of radiation sequelae, treatment has typically involved creation of either an ileal conduit or a cutaneous continent urinary diversion. As an alternative, a more limited resection with urinary tract reconstruction using ileum for interposition or augmentation may allow for the preservation of urethral voiding. CASES: We describe the use of ileal segments for lower urinary tract reconstruction in the treatment of ten patients with advanced or recurrent gynecologic malignancies. The clinical history, surgical technique, and patient outcomes are reviewed. DISCUSSION: These cases demonstrate that limited bladder or ureteral resection with reconstruction using ileal segments may offer select patients preservation of urethral voiding.     

Cytoreductive surgery in the primary management of advanced epithelial ovarian carcinoma: a topic for debate

While there is no doubt that surgical resection of early stage ovarian cancer can be curative, the effect of cytoreductive surgery on the prognosis in advanced disease is less certain. A recent EORTC study does suggest that intervention debulking surgery might improve survival and this requires urgent confirmation. Extensive cytoreductive surgery, removing bowel, parts of the urinary tract or lymph nodes, may have little impact on the survival of women with advanced disease and can result in substantial morbidity. Discretion and experience are required in determining the appropriate radicality of tumor resection to avoid predictable impairment of quality of life.     

A case of nephrogenic diabetes insipidus caused by partial bilateral ureteral obstruction due to advanced stage ovarian carcinoma

Nephrogenic diabetes insipidus (NDI) secondary to chronic urinary tract obstruction is a rare condition. The exact cause is unknown; it is likely that increased collecting duct pressures cause damage to the tubular epithelium, resulting in insensitivity to the antidiuretic hormone (ADH). We report a case of NDI associated with ureteral obstruction caused by advanced stage ovarian carcioma in a 20-year-old girl. After debulcking surgery, massive polyuria continued. Several administrations of an ADH analog were ineffective in reducing urine output, suggesting a possible relationship of massive polyuria with NDI. Following oral administration of a thiazide diuretic, known to exert antidiuretic action in NDI, the urine output was dramatically reduced. This case suggests that ureteral obstruction due to ovarian mass may cause NDI and after the surgery thiazide diuretics are effective in reducing urine output in NDI with ureteral obstruction.     

Ureteral assessment after radical hysterectomy

Postoperative intravenous pyelography was performed in 233 patients with stage IB cervical carcinoma treated with radical hysterectomy and pelvic lymphadenectomy between January 1962 and December 1985. Four patients developed symptoms of ureteral injury, two (0.8%) ureteral fistulae, and one (0.4%) stricture and obstruction due to recurrent carcinoma. No ureteral injuries were observed in 229 asymptomatic patients. A 5.2% incidence of transient severe ureteral dilatation occurred in asymptomatic patients, but resolved within a median of 94 days. A significant urinary tract anomaly was observed in 3.4% of preoperative pyelograms. All of these anomalies were apparent at surgery and presented no intraoperative difficulties. Three patients (1.3%) sustained intraoperative ureteral transections, which were diagnosed and repaired without sequelae. In patients with early cervical carcinoma having primary operative treatment, the role of routine preoperative and postoperative intravenous pyelography is questionable.     

Intraoperative gold grain implants for pelvic wall recurrences of various malignancies: toxicity, results, and failure analysis in 37 patients

PURPOSE: We conducted this study to determine the complications and long-term results of intraoperative gold-grain implants as therapy for pelvic wall recurrences of various malignancies. MATERIALS AND METHODS: We retrospectively analyzed complications and long-term results of intraoperative radioactive 198Au gold grain implants of 4-mc radon equivalent in 37 patients with pelvic wall recurrences of various malignancies treated at the University of Texas M. D. Anderson Cancer Center. The estimated dose was 30-100 Gy, which was increased to 100-120 Gy plus external-beam irradiation if the dose to the tumor volume was too low. All patients had follow-up of 4 months to 12 years. Of the 37 patients, 34 had lower leg edema, 22 had lower limb pain, and 22 had ureteral obstruction. RESULTS: Six of 34 patients with lower limb pain had partial relief and nine had complete relief. Of 22 patients with ureteral obstruction, ten had complete resolution and four had partial relief. Lower limb edema was improved in 16 of 22 patients. Of the 37 patients studied, 14 are alive and 23 have died. CONCLUSION: In selected patients, gold grain implantation to a dose of 70-100 Gy relieved some symptoms of unresectable pelvic wall recurrences of various malignancies. We believe that intraoperative gold grain implants appear to be the only useful treatment for patients with recurrent malignancies fixed to the pelvic wall and provide these patients with better and longer palliation and a good quality of life.     

Primary primitive neuroectodermal tumor of the urinary tract.

Primary primitive neuroectodermal tumor (PNET) of the urinary tract is a rare disease with aggressive behavior and poor prognosis. We analyzed 851 cases of urinary tract malignancies in our hospital between 1984 and 2004. Only three (0.035%) cases with PNET of the urinary tract were identified. Presenting symptoms included flank pain and hematuria. The first case was a 44-year-old man with left renal PNET who underwent hand-assisted laparoscopic radical nephrectomy and adjuvant chemotherapy. There was no recurrent tumor at the 4-year follow-up. The second case was a 75-year-old woman with right renal PNET with inferior vena cava (IVC) thrombosis extending to the right atrium. The patient underwent right radical nephroureterectomy and IVC thrombectomy with cardiopulmonary bypass. She died of metastatic disease 7 months later. The third case was a 45-year-old man with left ureteral PNET. Left ureteral segmental resection and partial cystectomy were performed. Tumor recurrence was noted 7 years later. The patient died of disseminated disease 1 year after the discovery of recurrence. Urinary tract PNET appears to be an aggressive malignancy. Long-term survival is possible if complete resection is performed at an early stage.     

Lower urinary tract injury during the Burch procedure: is there a role for routine cystoscopy?

OBJECTIVE: This study was undertaken to evaluate the use of intraoperative cystoscopy for the detection of incidental bladder or ureteral injuries during abdominal urethropexy procedures and to determine whether the incidence of injuries warrants the routine use of cystoscopy. METHODS: We reviewed the medical records of 109 consecutive patients who underwent abdominal urethropexy procedures between November 1990 and February 1996 at a teaching institution. Each underwent intraoperative cystoscopy. We determined the incidence of cystotomy and ureteral obstruction and attempted to determine surgical factors that might be associated with an increased risk of injury. RESULTS: Ten of 109 patients (9%) had bladder or ureteral injury, including 1 cystotomy during retropubic dissection, 6 cases of a transvesical suture noted during cystoscopy, 1 cystotomy recognized before closure, 1 case of ureteral obstruction found during cystoscopy, and 1 case of ureteral obstruction not recognized at cystoscopy. Cystoscopy allowed detection of 7 of 9 (78%) otherwise unrecognized events. The only injury that resulted in significant postoperative morbidity was the unrecognized ureteral obstruction. There was no association between incidence of lower urinary tract injuries and surgical risk factors. CONCLUSION: Intraoperative bladder or ureteral injuries during urethropexy procedures are not uncommon, with an incidence of 9% in our series. There is minimal morbidity if these injuries are detected and corrected during the operation, whereas morbidity may be significant if they remain unrecognized. With a potential for unrecognized injury in 8% of Burch procedures without the use of cystoscopy, routine use of cystoscopy during urethropexy procedures appears to be warranted.     

The use of intraoperative cystoscopy in major vaginal and urogynecologic surgeries

OBJECTIVE: Our purpose was to examine the frequency of significant intraoperative cystoscopic findings during major vaginal reconstructive and urogynecologic surgeries. STUDY DESIGN: The records of 526 consecutive women who underwent routine cystoscopy with intravenous injection of indigo carmine at the time of their urogynecologic and major vaginal reconstructive procedures between January 1, 1997, and April 20, 2001, were reviewed. We determined the incidence of significant cystoscopic findings and their effect on intraoperative management. Two-tailed t tests and logistic regression analyses were used to compare characteristics between the groups with and without significant cystoscopic findings. RESULTS: During the 526 operations, 26 significant findings (4.9%) were unsuspected before cystoscopy and 15 (2.9%) of these findings were operative injuries that required intervention. Seventy-nine subjects (15.0%) had no anti-incontinence operation performed. Of these patients, there was one partial ureteral obstruction from an anterior colporrhaphy (1.3%). Seven of 184 Burch procedures (3.8%) resulted in injuries to the lower urinary tract, of which 3 (1.6%) required intervention that were unrecognized before cystoscopy. Seven of the 15 cases resulting in changes in intraoperative management were caused by anterior colporrhaphy sutures (2.0% of all anterior colporrhaphies). There were no unrecognized injuries that caused morbidity after surgery. There were no significant differences between patients with abnormal and normal cystoscopic findings in regard to mean age, weight, parity, estimated blood loss, previous surgery, or previous incontinence surgeries. No complications or morbidity occurred as a direct result of intraoperative cystoscopy. CONCLUSION: Intraoperative cystoscopy with intravenous indigo carmine is a safe and effective way to detect injury of the lower urinary tract. Cystoscopy detected unsuspected operative injuries in 2.9%. In cases that did not involve anti-incontinence procedures, the rate of injury was 1.3%. With a significant rate of detection, cystoscopy allows for immediate recognition and easier repair of lower urinary tract injury, lowering the patient's risk for morbidity. Anterior colporrhaphy was the most common cause of unrecognized ureteral compromise.     

Splenectomy in cytoreductive surgery for advanced ovarian cancer

Methods To evaluate the series of advanced ovarian cancer patients who underwent splenectomy as part of their surgery, a retrospective file review of 258 ovarian cancer cases were examined.Results There were 13 cases that underwent splenectomy. These patients constitute 5% of all and 8.8% of the advanced ovarian cancer patients. Seven cases had splenectomy as part of their initial cytoreductive surgery while 6 had surgery for recurrent disease. Splenectomy was performed to resect hilar and/or capsular involvement in 9 (69%) cases, while in 3 cases (23%) splenic injury during adjacent tumoral resection required splenectomy. One patient had splenectomy for infarcts and died after the surgery with systemic complications nonrelated to the surgery. No other serious morbidity was detected. Median survival of the patients was 34 months (1–120 months) from the initial diagnosis. Median survival was 18 months (1–78 months) after the splenectomy. Three patients were still alive with no evidence of disease 2, 5 and 6.5 years after the splenectomy.Conclusion Splenectomy is a feasible and safe procedure. However, it should be reserved for patients in whom optimal cytoreductive results could be achieved.     

Ureteral obstruction: an unfrequent complication of Burch colposuspension. Report of two cases

The injury of the urinary tract in a pelvic surgery is inherent, its real frequency in which it presents, is difficult to establish, due that not all the lesions are published. In this article, two cases of ureteral obstruction posterior to a Burch-procedure, and the way they were resolved is reported. The ureteral obstruction is a very rare complication, but one that has the worst and severe medico-legal consequences, if they are not resolved opportunely. Its frequency in our service was of 0.41%, in 240 Burch-procedures that were realized during April of 1997 and June of 2000.     

Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group)

Study ObjectiveTo describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017.DesignMulticenter retrospective cohort pilot study.SettingDepartments of gynecology at 31 expert endometriosis centers.PatientsAll women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]).InterventionsSurgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database.Measurements and Main ResultsA total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis).ConclusionThe surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.     

An algorithm for diagnosis and therapy of management and complications of urolithiasis during pregnancy

From 1 January 1986 to 30 June 1989, 15 pregnant women were diagnosed as having urolithiasis. Patients presented in the last two trimesters with an infection of the lower part of the urinary tract (60 per cent), flank and abdominal pain (27 per cent) and hematuria (13 per cent). Ultrasonographic findings confirmed the diagnosis in 47 per cent of the patients. Other roentgenologic procedures were required in the remaining patients. Initially, therapy was conservative in all, and in 67 per cent of patients, no further intervention was necessary. Only 33 per cent required invasive measures; cystoscopic passage of an internal ureteral stent was the initial procedure of choice at our institution. Three of five patients who underwent invasive procedures had surgical intervention for relief of ureteral obstruction. Intensive care management was necessary for one of these three patients who had acute hemorrhage occur during the procedure. These data emphasize the need for the accurate diagnosis of urolithiasis during pregnancy. Ultrasonography was a valuable diagnostic technique, but a limited excretory urogram is safe and appropriate when there is uncertainty. Conservative management (hydration, analgesia and antibiotics as indicated) of obstructive uropathy was successful in the majority of instances. A specific clinical algorithm facilitated the successful management of patients necessitating operative intervention. Optimal management requires clinical suspicion and a precise diagnostic and therapeutic plan.