Bririsk Journal of Urology (1976), 48, 555-560

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Reflux Induced Pelvi-ureteric Obstruction ROBERT H. WHITAKER

Department of Urology, Addenbrooke's Hospitol, Coinbridge

The purpose of this paper is to consider the pelvi-ureteric obstruction which is occasionally seen in association with vesico-ureteric reflux in the light of recent and more critical reappraisal of hydronephrosis (Whitaker, 1975, 1976). With the advent of image intensification and good quality micturition cystourethrography it was soon recognised that a marked degree of reflux could result in an appearance of the renal pelvis suggestive of pelvi-ureteric obstruction (Gross and Sanderson, 1961; Hutch, Hinman and Miller, 1962). In these early descriptions it was not stated how long the pelvis remained full after voiding was completed so that no real evidence of an obstruction was presented. However, Hutch et al. (1962) did suggest that in the presence of a closed type of renal pelvis (Hanley, 1959) reflux could induce a hydronephrosis which remains, and perhaps even becomes symptomatic, long after the reflux has spontaneously stopped. Shopfner (1966) made the important observation, sadly all too often forgotten, that not all dilated renal pelves, with or without reflux, are obstructed. But he agreed that reflux, perhaps with infection, could play a major role in the pathogenesis of pelvi-ureteric obstruction. He stressed the need to see how quickly the pelvis empties after voiding in determining whether or not a meaningful obstruction is present. Smith (1970) from his own experience and a review of the literature states that the pelviureteric obstruction seen with reflux is usually secondary to the ureteric changes that accompany reflux. He does concede, however, that the pelvi-ureteric obstruction could be a primary abnormality of the idiopathic type and the reflux incidental as both conditions occur in a similar age-group. Williams (1974) accepts 2 distinct groups. 1 with pelvi-ureteric obstruction which presents as a renal problem and needs a pyeloplasty. The reflux which is incidental and irrelevant to the aetiology of the hydronephrosis may stop spontaneously after the pyeloplasty. A second group develop hydronephrosis, which may become obstructed, as a result of massive reflux into the pelvis. At operation there is a secondary kinking at the pelvi-ureteric junction with some narrowing but the exact site of hold up is not altogether obvious. In this latter group the pelvis balloons during micturition and remains full. Williams suggests that this is due to atonicity of the pelvic musculature. This phenomenon can disappear after reflux prevention when the pelvi-ureteric junction is called upon to cope only with the normal downward urine load and he believes that the findings of this type of pelvis is a relative indication for reflux prevention. Johnston (1976) suggests that the aetiology of the obstruction is the sudden gross filling of the renal pelvis with refluxed urine which leads to an increased pelvi-ureteric angulation and subsequent severe pelvic distension and delayed emptying. Thus it is clear that although descriptions of this condition abound, few if any attempts have been made to define at what stage such a reflux induced hydronephrosis has a significant degree of obstruction and needs surgical attention; the term obstruction is often loosely used. Shopfner (1966) could see that the answer lay in dynamic assessment and attempted to analyse obstruction Rend at the 32nd Annual Meeting of the British Association of Urological Surgeons in London, June 1976. 4817-D 555

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Fig. I . I-year-old boy with recurrent urinary tract infections. A, Urogram with n o suspicion o f hydronephrosis. B, Micturating cystogram showing gross reflux with pelvic distension suggesting possible secondary pelvi-ureteric obstruction

particularly o n the right. However, both pelves drained readily alter micturition.

on these lines but found the results sufficiently variable to be of no convincing value. Hutch and Tanagho (1965) discussed the theoretical aspects of the dynamics of this type of obstruction but did not put their theories to practical or clinical use.

Objectives The sometimes remarkable contrast between the appearances of the renal pelvis and the calyces i n the urogram and the micturating cystogram may lead one to suspect too easily an element of pelvi-ureteric obstruction where none exists (Fig. 1 ) . The objective was to assess the best mcans of diagnosing a true obstruction secondary to reflux.

Clinical Studies During micturating cystography in patients who show reflux we watch carefully to see how long the renal pelvis remains full and have been surprised how readily the most grossly distended pelvis can empty after voiding has ceased. I n the few that have remained a little full we have found it difficult to assess the significance because of several variable factors which include the degree of dehydration and the position and co-operation of the patient.

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Fig. 2. A , Urogram and, B, Micturating cystogram of a 5-year-old boy with urinary tract infection and bouts of left loin pain. There I S a gross discrepancy between the 2 appearances. After micturition the left renal pelvis remained full after the ureter had emptied. After a left ureteric re-implantation he has had no further pain and the follow-up urogram shows no pelvic dilatation.

The patients of particular interest are those with no suggestion on the urogram of a hydronephrosis but who have marked pelvic dilatation on voiding. In other words, patients in whom there is no suggestion of a primary pelvi-ureteric obstruction. The degree of pelvic dilatation and appearances suggestive of obstruction are variable even in the same patient. Figure 1 shows the urogram and cystogram of a young boy with repeated urinary infections. The right side is more suggestive of a secondary pelvi-ureteric obstruction but in fact both emptied readily after voiding. Figure 2 shows a boy with a similar history but his renal pelvis took several minutes to empty and this was a factor that influenced our decision in this child to re-implant his ureter. Figure 3, A shows the urogram of a child in whom detailed studies were possible. It shows a small scarred, dysplastic lower pole of a duplex left kidney. There is no suggestion on this urogram of a primary pelvi-ureteric obstruction. On filling his bladder with contrast medium it ran freely up into this lower pole pelvis (Fig. 3, B). On voiding, the pelvis rapidly fills and in this boy it remained full for the several minutes that it took to complete this study (Fig. 3, c). Because he had such a poor lower pole a partial nephroureterectomy was undertaken and at the time of operation the pelvi-ureteric junction was studied. Because our pressure/flow apparatus

Fig. 3. A 9-year-old boy nith an 8-month history of left sided pain and urinarv tract infection. He had reflux into a small scarred lower pole of thhduplex left kidney. A, Urogram. Poor excretion but no suggestion of a hvdronephrosis. B, During bladder filling there is partial distension-of the left renal pelvis. C, Just after finishing voiding. The pelvis remained full for several minutes even with the patient standing.

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was not available at that time a syringe filled with saline was used to fill the system. The needle was inserted into the lumen of the ureter 3 inches below the pelvi-ureteric junction with the ureter temporarily occluded below that level. The pelvis was initially flaccid but filled and became rounded as the saline was injected. When the pelvis was tense the syringe was removed and the ureter released. The pelvis remained full and tense and the pelvi-ureteric junction would conduct no fluid even when the pelvis was squeezed. The situation now had the typical features of an idiopathic type of pelvi-ureteric obstruction. A partial nephroureterectomy was then completed.

Discussion Atonicity (Williams, 1974) and acute angulation (Johnston, 1976) may well play a part in the production of this phenomenon but in the truly obstructed pelvis further factors are probably involved. It is clear that the easy distensibility of the pelvis in these cases converts a funnelshaped pelvi-ureteric junction into a shape not unlike a plug-hole in a bath. The downward propagating pelvic contraction wave can no longer form a bolus but having failed to do so the circular component contracts at the first point of occlusion and this action actively obstructs the lumen. The implication here is that this is an active, as opposed to passive, obstructive phenomenon and akin to that seen in the idiopathic form of pelvi-ureteric obstruction (Whitaker, 1975). As others have suggested (Hutch et a/., 1962) some renal pelves are more susceptible to becoming obstructed in the presence of reflux but whether the defect is primary or secondary to the reflux is largely an academic argument. As far as treatment is concerned, and particularly if pyeloplasty is being considered, it is essential to decide whether or not a significant degree of true obstruction is present. More evidence is needed than a full pelvis at the height of voiding. Considerably delayed emptying is suggestive of obstruction but this is a situation in which a pressure/flow perfusion study, performed percutaneously under radiographic control, could supply the absolute evidence of obstruction that is needed. In the group with urographic appearances suggestive of a pelvi-ureteric obstruction the diagnosis of obstruction must first be confirmed and a pyeloplasty performed. In the second group where there is so often a severe dysplasia or renal reduplication but the urogram shows no hydronephrosis, the choice of treatment is a re-implantation of the ureter or a partial or total nephroureterectomy. A pyeloplasty will only be necessary in this group if the diagnosis of obstruction is substantiated after a re-implantation. Finally, it is of interest to speculate whether the occasional patient with a large renal pelvis a little suggestive of pelvi-ureteric obstruction but with a wide ureter below it and no reflux may have had spontaneous cessation of reflux and this is the aftermath. This would be an explanation for the non-obstructed hydronephrosis which undoubtably exists (Shopfner, 1966; Whitaker, 1975).

Summary The phenomenon of pelvi-ureteric obstruction which is induced by vesico-ureteric reflux is well documented but ill understood. The radiographic findings can be impressive to an extent that obstruction is probably often over-diagnosed. Before considering a pyeloplasty it is essential to confirm the true obstructive nature of the problem. Where the urogram is not suggestive of an obstruction a re-implantation of the ureter will usually stop the gross pelvic dilatation. It is suggested that the obstruction is at least partially an active process.

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References GROSS, K. E. and SANDERSON, S. S. (1961). Cineurethrography and voiding cinecystography with special attention to vesico-ureteral reflux. Radiology, 77, 573-585. H . G . (1959). The pelvi-ureteric junction: a cinepyelography study. British Journd o f Urohxj., 31, 377HANLEY, 384. HUTCH,J. A., HINMAN, F. and MILLER,E. R.(1962). Reflux as a cause of hydronephrosis and chronic pyelonephritis. Journal of Urology, 88, 169-175. E. A. (1965). Etiology of non-occlusive ureteral dilatation. Jorirul of Urology, 93, HUTCH,J. A. and TANAGHO, 177-184. JOHNSTON, J. H. (1976). In Urology, ed. J. P. Blandy. Oxford: Blackwell, p. 545. SHowNER, C. E. (1966). Ureteropelvic junction obstruction. Anirrican Joirrnul of Rornfgenolog,v unil Ratlirrrn Therupy, 98, 148-159. SMITH,D. R. (1970). In Urology, ed. M. F. Campbell and J . H. Harrison, 3rd ed. Philadelphia: Saundcrs, vol. I, pp. 365 and 366. WHITAKER, R. H. ( I 975). Some observations and theories on the wide ureter and hydronephrosis. Briridi Jorrrnul of Urology, 47. 377-385. WHITAKER, R. H. ( 1975). Equivocal pelviureteric obstruction. British Jortrnul of Urology, 47, 771-779. WILLIAMS, D.1. (1974). In Eifc,ycloprtliaof Urology, X V Supplement. Berlin: Springer, pp. I19 and 125.

The Author Robert H. Whitaker, MChir, FRCS, Consultant Urologist. Ilcquests for reprints to the author at Addenbrooke's Hospital, Cambridge.

Reflux induced pelvi-ureteric obstruction.

The phenomenon of pelvi-ureteric obstruction which is induced by vesico-ureteric reflux is well documented but ill understood. The radiographic findin...
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