**1. Introduction**

260 Chronic Kidney Disease

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Obstructive nephropathy is a term describing the damage to the renal parenchyma that results from the obstruction to the flow of urine anywhere along the urinary system. Long term obstruction causes chronic renal disease. Obstruction coexisting with infection and impaired renal function, when complicated by elevated temperature and leukocytosis that can lead to septic shock, are an absolute indication for urinary diversion such as percutaneous nephrostomy. This particular patient needs emergency diversion. One of the most common indications of nephrostomy placement is ureteric obstruction causing uremia. It is therefore necessary to make the patients fit enough for the designated surgery.

Percutaneous nephrostomy involving supravesicle drainage is one of the most common procedures in urologic practice. Goodwin described a trocar nephrostomy technique in a markedly dilated kidney in 1955. (Goodwin et al., 1955). Percutaneous nephrostomy is performed for temporary or permanent supravesicle urinary diversion. The treatment goals in patients with malignant ureteric obstruction are symptom relief and avoidance of any complications from renal insufficiency. Permanent nephrostomy has been used in patients with obstruction from uncorrectable causes such as inoperable tumors. (Table 1)

The indication of nephrostomy tube placement depends on whether the procedure is elective or urgent. The purpose of nephrostomy tube placement in obstructive renal disease is to preserve kidney function and drain infected urine. Establishing a safe and reliable nephrostomy tract is key that range from simple urinary drainage to intrarenal surgical operation. (Fig. 1-4)

Complications of obstruction as sepsis and pain. Improve renal function. Localized disease that additional therapy may prolong survival. Improve quality of life. Independent existence at home possible. Table 1. Indication for palliative diversion.

Modern Surgical Treatments of Urinary Tract Obstruction 263

Fig. 2. Nephrostogram following nephrostomy tube placement due to azotemia and

Fig. 3. Percutaneous nephrostomy in patient with complete distal ureteral obstruction from

pyonephrosis demonstrated impacted upper ureteric calculi.

advanced cervical cancer.

Careful discussion between patients, relatives and health care professionals about nephrostomy tube placement must be undertaken before the intervention because patients will require a drainage bag which reduces the quality of life.

Renal function in several patients recover following temporary percutaneous nephrostomy tube placement. The definite treatment is need prior nephrostomy tube removal. Advance in endourologic instrumentation and techniques, endourologic operations as the minimally invasive surgery (percutaneous nephrolithotomy, endopyelotomy, infundibulotomy and endoureterotomy) are the procedure of choice for these patients. The nonfunctioning kidneys following the diversion usually require nephrectomy.

Fig. 1. Bilateral percutaneous nephrostomy in a patient with right upper ureteral calculi and bilateral renal calculi presenting of anuria.

Careful discussion between patients, relatives and health care professionals about nephrostomy tube placement must be undertaken before the intervention because patients

Renal function in several patients recover following temporary percutaneous nephrostomy tube placement. The definite treatment is need prior nephrostomy tube removal. Advance in endourologic instrumentation and techniques, endourologic operations as the minimally invasive surgery (percutaneous nephrolithotomy, endopyelotomy, infundibulotomy and endoureterotomy) are the procedure of choice for these patients. The nonfunctioning

Fig. 1. Bilateral percutaneous nephrostomy in a patient with right upper ureteral calculi and

bilateral renal calculi presenting of anuria.

will require a drainage bag which reduces the quality of life.

kidneys following the diversion usually require nephrectomy.

Fig. 2. Nephrostogram following nephrostomy tube placement due to azotemia and pyonephrosis demonstrated impacted upper ureteric calculi.

Fig. 3. Percutaneous nephrostomy in patient with complete distal ureteral obstruction from advanced cervical cancer.

Modern Surgical Treatments of Urinary Tract Obstruction 265






Signs, symptoms and degree of obstructive nephropathy depended on the following factors:

The presenting symptoms of bilateral and chronic obstruction can be nonspecific such as increases in abdominal girth, ankle edema, malaise, anorexia, headache, weight gain, fatigue

Ultrasound is the most valuable tool of radiologic assessment of obstructive uropathy in patients with azotemia, even in pregnant and pediatric patients. This investigation provides information about both renal parenchyma and the collecting system. Hydronephrosis is demonstrated as a dilated collecting system separating the normally echogenic renal sinus. Echoes within the collecting system may indicate pyonephrosis, hemorrhage or a lesion of the transitional mucosa. The thickness of the renal parenchyma can be represented the

Ultrasonography for diagnosing obstruction can provide false positive (overdiagnosis) and false negative (missing an obstruction) results. The conditions that can cause false negatives with ultrasonography are acute onset of obstruction, an intrarenal collecting system,





Table 2. Common etiologies of urinary tract obstruction.



**Extrinsic causes** : Genitourinary system

: Gastrointesinal system

: Retroperitoneal pathology

: Vascular system

**Intrinsic causes** : - Nephrolithiasis

**2.2 Clinical presentation** 

and shortness of breath.

duration of obstruction.

**2.3.1 Ultrasound** 

**2.3 Radiographic assessment** 


Fig. 4. Percutaneous nephrostomy at upper calyx due to complete upper ureteral obstruction from previous surgery. (single kidney)
