Urologyspecialist.com.au

Common presentations
•  Intermittent abdominal and flank pain
- May be associated with nausea and vomiting

•  Incidentally found during investigation of
- Azotemia
•  Obstruction of a functionally or anatomically solitary
- Haematuria
- UTI, pyuria
Approach to Mx
•  Acute obstruction (urosepsis, azotemia with
solitary kidney, pain with UTI)
- Relieve obstruction
- Investigate once settled
•  No acute problem
- investigate
Goal of investigation
•  Determine anatomic site
•  Functional significance
•  PUJ obstruction is defined as functionally
significant impairment of urinary transport
from renal pelvis to ureter
•  Delayed emptying with dilated pelvicalyceal
system & normal ureter
•  If intermittent there may be normal imaging
between episodes
Investigations
•  Ultrasound
- Good in neonates
- Demonstrates hydronephrosis
- Can distinguish between hydronephrosis and
multicystic kidney
- Useful if there is poor excretion of contrast of
nuclear isotope
•  Constrast CT
- Demonstrates hydronephrosis with site of
obstruction
- Not quantitative
Investigations
•  IVP
•  DTPA
- Good concentration of isotope even with
decreased parenchyma (but not if multicystic)
- Quantitative, lasix, position
•  RGP
- Done at time of repair (to prevent introduction of
infection)
- Identifies anatomy (rest of ureter)
- Decompresses system
Investigations
•  Percutaneous nephrostomy
- Can be done if too sick
- Allows pressure study
•  >15cm H20 suggests functional obstruction
- invasive
Indications for intervention
•  Acute obstruction
-  Sepsis
-  Pain
•  Impaired renal function
•  Progressive decrease in ipsilateral renal function
•  Stones
•  Recurrent infections
•  Observe if asymptomatic or physiological
significance not clear
•  Nephrectomy if nonfuctioning or multiple repairs
Endoscopic Interventions
•  Retrograde
- Hot cutting wire ballon endopyeloplasty
- Ureteroscopy and holmium laser
•  Antegrade if stones are present as well
•  Contraindications
- Stricture >2cm
- Infection
- Coagulopathy
Open or Lap
•  Pyeloplasty
- Open
- Laparascopic
•  If one endoscopic fails try open/lap or vice
Pathogenesis
•  Most commonly congenital
- May present at any age
- Aperistaltic segment of ureter
•  Spiral muscle replaced by longitudinal muscle or
fibrous tissue
•  Failure to propel a wave of urine into ureter
•  Lower pole arteries present in 1/3
- Functional significance unclear
- May cause obstruction of posterior to ureter
Pathogenesis
•  Intrinsic disease
- Infolding or kinks of ureteral mucosa or
musculature
- Retention of congenital folds
- External bands or adhesions
- Angulation or ureter at renal pelvis
•  Ureteral insertion carried proximally leading to
inadequate drainige of lower pelvis
Pathogenesis
•  Acquired
- Stricture is less common
•  Eg iatrogenic
- Reflux in kids may cause dilated, tortuous ureter
with kinks that may mimic radiological PUJ
obstruction

Source: http://www.urologyspecialist.com.au/uploads/adult_puj_obstruction.pdf