Urinary Tract Obstruction

1. Nephroureterectomy

It is a procedure done to remove the entire affected kidney along with its adjoining ureter. This is only done if the draining kidney is non-functional or is posing the threat of sepsis which can be fatal.

2. Relieving the pressure

Since the urine gets collected in the urinary tract, it is essential to relieve the pressure. This is done when

• There is complete obstruction of the urinary tract  
• The obstruction is leading to renal failure 
• There are fever, infection and refractory pain (uncontrollable pain) along with the obstruction

For relieving the pressure caused due to an upper urinary tract obstruction, ureteral stenting is performed. A ureteric stent is a thin, flexible plastic tube which is also known as a J-J stent or double-J stent because it is curled at both ends. This curling up of the tube prevents any damage to the kidney and the bladder. The stent is placed in such a manner that its upper-end sticks into the kidney and its lower end stays in the urinary bladder.

For relieving pressure caused due to lower urinary tract obstruction, urethral catheterization is done with a Foley’s catheter. In this procedure, a tube called Foley’s catheter is inserted into the bladder through the urethra.

When there is a complete obstruction and Foley’s catheter is not helpful, suprapubic urethral catheterization is done. In this type of catheterization, a tube-like structure is inserted directly into your bladder by making a small hole in the abdomen. 

Once the emergency situation is handled and the complete obstruction has been managed, the urologist can treat the underlying cause.

All the patients receive primary treatment which involves the administration of analgesics such as non-steroidal anti-inflammatory drugs (aspirin and ibuprofen) or morphine (given intravenously). The patients are also given antibiotics prophylactically, even in the absence of infection.

Following treatment procedures are used for upper urinary tract obstruction:

1. Nephrolithiasis or kidney stones

For the treatment of kidney stones, the following procedures are used:

• For nephrolithiasis, doctors initially treat the condition conservatively with pain controlling medications and other medications such as alpha-blockers and calcium channel blockers which can help relieve the condition. 
• Patients with stones of size greater than 10 millimetres (mm) which do not pass even after four to six weeks and clinical symptoms such as vomiting, anuria (no passage of urine), unbearable pain, sepsis may require invasive treatments such as shock wave lithotripsy (SWL). In SWL, the doctor administers a series of shock waves to break the kidney stone which can then travel through the urinary tract and pass from the body more easily.
• For patients with harder stones which are larger than 1.5 cm, ureteroscopy (examining the uterus using a small telescope) is done to find out the actual location of the stones. After that percutaneous nephrolithotomy is done to remove the stones, where the surgeon enters the kidney by making a small incision in the back. Then the surgeon inserts a nephroscope (a miniature fiberoptic camera) and other small instruments such as a tube into the hole to remove the entire stone.
• Rigid and firm stones can also be removed laparoscopically (through keyhole surgery).  

2. Ureteral stricture

Ureteral stricture means narrowing of the tube which connects kidneys and the bladder. The following treatments are used to relieve stricture in the ureter(s):

• Transluminal balloon dilation: This treatment is done in the case of short strictures. In this procedure, the doctor inserts a balloon into the ureter along with a catheter (tube) and then the narrowed portion is widened by inflating the balloon. The doctors may use stents to prevent the ureter from narrowing again. 
• Endoureterotomy: This process is mostly used if balloon dilation fails. It can involve the use of lasers and stents to relieve the stricture.
• Laparoscopic surgery: Laparoscopic surgery is only done if other less invasive measures fail.

3. Pregnancy

If the obstruction is present due to pregnancy but the patient has no signs of infection, then no treatment is given. Most of these obstructions resolve spontaneously after delivery. But if the pregnant woman presents with signs of infection, then the obstruction is treated with the help of antibiotics, fluid therapy and ureteral stenting. 

4. Unknown mass in the abdomen 

If the mass is malignant, then the cancer is treated accordingly. Meanwhile, the obstruction is treated with the help of ureteral stenting or nephrostomy tubes. Nephrostomy is a procedure in which a tube is inserted through the skin into the kidney to directly drain the urine.

5. Aneurysm

In case of an aneurysm, the treatment involves surgical removal of the aneurysm followed by repair of the artery or vein. 

Following treatment procedures are used for lower urinary tract obstruction:

1. Bladder stone

For the removal of the bladder stone, one of the following procedures may be used:

• Urine pH: Sometimes the doctor may alkalinize (increase the pH) your urine with potassium citrate so that the stones get dissolved in the body.
• Transurethral cystolitholapaxy: In this procedure, the surgeon inserts a small tube with a camera at the end (a cystoscope) from the urethra, up into the bladder. While the camera helps to locate the bladder stones, either lasers or ultrasound waves are transmitted from the cystoscope to break up the stones into smaller pieces, which can be washed out of the bladder with urine.
• Percutaneous suprapubic cystolitholapaxy: In this procedure, the tube with the cystoscope is inserted by making a small cut in the skin of the lower abdomen and the stones are removed by making another cut in the bladder.
• Suprapublic cystostomy: A suprapubic cystostomy is done in the case of large intact stones. It is quite similar to percutaneous suprapubic cystolitholapaxy, but in this surgery, the cut is comparatively larger.

2. Bladder dysfunction due to neurological damage (neurogenic bladder) 

Doctors may give the patient medications such as alpha-blockers and other cholinergic drugs to help increase the flow of urine. Other treatments for a neurogenic bladder are:

• Intermittent self-catheterization: In this procedure, a plastic tube called a catheter is placed from the urethra into the bladder to allow the urine to drain freely out of the bladder. Once the bladder is empty, the tube is removed.
• Bladder augmentation: Bladder augmentation is done so that the bladder can store larger amounts of urine without leading to high pressures or urine leakage.
• Urinary diversion: Urinary diversion is a surgical procedure in which the surgeon reroutes the normal flow of urine out of the body when urine flow is blocked in the normal route. It is done as a last resort when all the other treatments fail. 

3. Urethral stricture

Urethral stricture means narrowing of the tube which helps to pass the urine from the bladder. In case of short strictures, transluminal balloon dilation, urethrotomy (a surgical procedure to widen the urethra) and urethral stents are used to widen the urethra. For long strictures, urethroplasty is done where the entire urethra is replaced or reconstructed surgically.

(Consult a doctor with doctor consultation app)