Obstructive uropathy

Summary A patient with primary linitis plastica of the colon has been presented. The unusually aggressive nature of this tumor is demonstrated in a young man who presented with obstructive uropathy. Extensive renal involvement is a rare complication of this disease, and obstructive uropathy is a previously undescribed presentation. If early recognition is to favorably alter prognosis, then awareness of this form of colonic malignancy is essential.     

Obstructive uropathy in childhood

"Obstructive uropathy" is a generic term which combines different diseases in infants and childhood. Both the upper and lower urinary tract may be affected. Diseases of the urinary tract can cause an intrinsic obstruction. Sometimes tumours may cause a compression and as secondary effect an obstruction (extrinsic). Ultrasound is the key diagnostic tool and shows dilatation of the obstructed urinary tract. But for the functional exploration of babies and toddlers, renal scanning and X-ray examinations are necessary. These examinations lead to an exposure to radiation which necessitates careful indication. Some of the congenital diseases (for example ureteropelvic junction obstruction, megaureter) show a maturation without any intervention. So one has to decide whether to wait and see or to operate. A percutaneous nephrostomy or a DJ-catheter is not often used in the treatment of obstruction in general. These forms of drainage are more often used in the treatment of stones or of extrinsic obstruction. A pyelocutaneostomy or ureterocutaneostomy is a special surgical procedure in pediatric urology for transient drainage of the upper urinary tract (megaureter). The operation of a seriously ill new-born should be done in a centre for pediatric urology and pediatric nephrology. When the upper urinary tract is dilated, patients may need an antibiotic prophylaxis, because the dilatation of the upper urinary tract increases the risk of urinary tract infections (UTI). The indication for antibiotic prophylaxis should by guided by the criteria of the APN-Consensus Paper. Long-term follow-up is necessary and should comprise ultrasound, physical examination, controlling the blood pressure, urine analysis and blood tests. The aims of diagnostics, treatment and long-term follow-up are the preservation of renal function and to protect the children from UTI. This goal must be reached under conditions that are appropriate for children and their parents.     

Obstructive uropathy in adults

Urinary tract obstruction is a common clinical problem. The obstruction of the urinary flow may be acute or chronic, partial or complete, unilateral or bilateral, and may occur at any site of the urinary tract. The major causes of urinary tract obstruction vary with the age of the patient. Anatomic abnormalities, e. g. ureteropelvic junction obstruction, account for the majority of cases in children. In comparison, calculi are most common in young adults, while prostatic hyperplasia or carcinoma, retroperitoneal or pelvic neoplasms, and calculi are the primary causes in older patients. Urinary tract obstruction results in different pathophysiological changes causing various symptoms. In addition to the aetiology, pathophysiology and clinical presentation of obstructive uropathy in adults, modern diagnostic and therapeutic options are presented in this review.     

Obstructive uropathy secondary to sigmoid diverticulitis

From a review of the literature and detailed study of 16 cases, the authors believe that ureteral obstruction in diverticulitis is more common than is apparent from the literature. They suggest that urograms be performed preoperatively in patients destined to undergo intestinal surgery. Management of the intestinal disease need not be altered from that initially planned for treatment of diverticulitis except with the proviso that the retroperitoneum be examined for the presence of a fibrotic inflammatory reaction. If this is found, they suggest that ureterolysis of the involved ureter be performed to allow relief of this obstruction.     

Obstructive uropathy after pan-proctocolectomy for ulcerative colitis.

We report two cases of pan-proctocolectomy for ulcerative colitis who some time postoperatively developed an obstructive uropathy with the clinical and radiological features of retroperitoneal fibrosis. The incidence of this complication appears to be around 10% and the possibility of such a diagnosis should be borne in mind in any patient who has non-specific symptoms after surgery for ulcerative colitis.     

Obstructive uropathy in two Chinese patients with lupus interstitial cystitis

We report herein two patients who presented with bilateral hydronephrosis attributed to lupus cystitis with two totally different clinical consequences. Both had systemic lupus erythematosus complicated with nephritis and nephrotic range of proteinuria. During the investigation of their proteinuria, they were noted to have a dilated collecting system. The site of obstruction was localized at the vesicoureteric obstruction by excretory urogram. The hydronephrosis resolved spontaneously in one patient before the commencement of any medical therapy, whereas in the other patient, there was no response to steroid therapy. Augmentation enterocystoplasty was thus performed. Reversible hydronephrosis caused by vesicoureteric junction obstruction in patients with systemic lupus erythematosus has been reported. Immune-mediated vasculitis involving the ureter and bladder mucosa was the postulated pathogenic mechanism. The condition usually showed good clinical response upon immunosuppressive therapy. We conclude that systemic lupus erythematosus-associated interstitial cystitis can have a spectrum of different prognoses.     

Hypoplastic pulmonary arteries and aorta with obstructive uropathy in 2 siblings

Two sisters who presented with diffuse hypoplasia of pulmonary arteries, relative hypoplasia of ascending aorta, obstructive uropathy, bilateral ureteral reflux, and hydronephrosis, are described. The subsequent course was characterized by progressive and gradual onset of right heart failure, failure to thrive, chronic malabsorption and systemic hypertension. The syndrome which appears to be transmitted by autosomal recessive inheritance can possibly represent a generalized hypoplasia and growth failure of a part or the entire arterial system. Peripheral pulmonary stenosis can occur as an isolated lesion or in association with other congenital cardiac anomalies, as well as in rubella syndrome and the syndrome of supravalvular aortic stenosis. This communication reports two siblings with a hitherto unreported combination of hypoplastic pulmonary arteries, and aorta with identical genito-urinary tract abnormalities.     

Renal aspergillosis giving rise to obstructive uropathy and recurrent anuric renal failure

A sixty-year-old previously healthy male patient presented with anuric renal failure of sudden onset. He was detected to have Aspergillus fumigatus fungal balls in the renal pelvis, ureters and bladder which were removed and his renal function improved. He was treated with itraconazole and sent home. Three weeks later he again presented with anuria and renal failure. He had recurrence of the obstruction with the same fungus. The fungal ball was removed, a double 'J' stenting was performed and he was treated with amphotericin B and itraconazole. Hence we report a previously healthy patient with no evidence of immunosuppression presenting an obstructive anuric renal failure due to isolated renal aspergillosis.