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Dr. Andrew Rynne

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What causes urinary tract obstruction?

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Dr. Manuel C See IV

Urologist

Practicing since :2005

Answered : 769 Questions

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Posted on Sat, 30 Aug 2014 in Urinary and Bladder Problems
Question: Hello, my mother has been diagnosed with urinary tract obstruction. Mentioned below are the series of events

18 months before
-     She was not passing urine as expected. Her urine outflow was not regular. She has swelling all over body including face, hands and legs. She was vomiting frequently.
-     After performing sonography, urologist diagnosed her with kidney stone. She was given water therapy for 2 days and saline water. After this treatment, her urine flow was back to normal for one month
-     Her creatinine was 2.8. After treatment it was back to 1.2

16 months before
-     She experienced similar symptoms again. This time we consulted another urologist who performed sonography again.
-     He diagnosed my mother with urinary tract obstruction and infection.
-     He performed minor operation to fit stents in both tract. He asked us to visit again after 3 months.
-     Her creatinine was 4.4. After treatment it was back to 1.2

12 months before
-     Doctor removed stents and kept her under observation for one day.
-     Within a week time frame, she experienced same symptoms again. This time doctor put stents that can last for 12 months

6 months before
-     New stents failed in 5 months and she experienced symptoms similar to kidney dysfunction. She was not able to pass urine at all. Not a single drop.
-     We admitted her to hospital. There she undergone citiscan and other blood tests. No cancer or TB was detected from blood test.
-     Her creatinine was 6.8. Doctors started treatment with heavy dose of medicines and saline/ glucose water. She was kept under observation for 10 days in hospital.
-     After bringing creatinine to 1.5 and reducing swelling, doctor fitted stent. She was back to normal again.
-     Doctor prescribed protein tablets and multi vitamin medicines and asked us to admit her after 6 months. Doctors were hopeful that she will recover and she should be able to pass urine after 6 months.

Now
-     She was all healthy and there were no issues except mild pain in abdomen.
-     We admitted her again to remove stents.
-     Doctor removed stent and doctor was hopeful that she will pass urine on her own.
-     She could not pass urine whole night, she vomited out thrice and kidney dysfunction symptoms like nausea, swelling, vomiting returned immediately.
-     Next morning doctor suggested to fit stents again to stop symptoms and bring down the swelling.
-     Doctor could fit stent only in one tract. The other tract was very tight and was not opening up.
-     They detected edema on the second tract.

Course of action suggested by doctor:
-     They are confused because kidney is healthy. Current creatinine reading is 1.2
-     They could not find anything wrong. They said such cases are resolved after one or 2 repetitions of stent replacement.
-     They did not detect cancer or TB.
-     They asked that we wait for 15-20 days to allow swelling (edema) on urinary to come down and they will try again to fit stent in second tract.
-     They have no answer on why this is happening. There is a minor swelling(edema) detected in sonography but nothing more than that.

Questions:
-     Do you see a pattern in these events? What can be the problem in this case? What treatment plan do you suggest.

Really appreciate your valuable feedback on this matter.
doctor
Answered by Dr. Manuel C See IV 2 hours later
Brief Answer:
Ureteral surgery and repair might be needed.

Detailed Answer:
Good day and thank you for being with healthcare magic!

Did any of your doctors do a CT SCAN of the abdomen ? with ct scan 90% of stones will be detected. If your mother has ureteral stricture that is causing her obstruction the ctscan and retrograde pyelogram would determine the length and location of the stricture.

For ureteral strictures i would recommend reparing the ureter and removing the strictured part either by open or laparoscopic surgery since conservative management with stents obviously is not working.

I hope I have succeeded in providing the information you were looking for. Please feel free to write back to me for any further clarifications at: http://www.HealthcareMagic.com/doctors/dr-manuel-c-see-iv/66014 I would gladly help you. Best wishes.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Manuel C See IV 23 hours later
Thanks for your quick reply. Appreciate it. I have few follow up questions.

- Repairing the ureter - Does this mean opening up the strictured part? What exactly surgeons do to repair the ureter.
- Removing the strictured part either by open or laparoscopic surgery - Does the strictured part needs to be replaced with artificial part? If yes, what is the lifetime of the artificial part?
- She was not able to pass urine at all for 24 hours after both stents were removed. Doctor fitted one stent in one of the ureter and another ureter is with no stent as it is blocked. She is now able to pass urine because there is one stent. Her current creatine is 3.9. She is on IV and not able to eat a lot as she feels heaviness in stomach. doctor suggested to do CT scan after her creatine is back to normal. They will do CT scan on Monday. I will update you on CT scan outcome.
doctor
Answered by Dr. Manuel C See IV 2 hours later
Brief Answer:
Pls see detailed explanation.

Detailed Answer:
thank you for your follow-up question.

Repair of the strictured part means removing the narrowed portion and connecting the non-diseased (healthy) ureters together without the use of any artificial part. Usually we place a stent after the repair and will be removed after 3 months. Success rates of stricture repair ranges from 80-90%.

I am surprised that a ct scan was not yet done to your mother. Pls do update me on the ct scan result.

Regards,

Manuel C. See IV, M.D. DPBU FPUA


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Manuel C See IV 44 hours later
Hello Doctor,

My mother's CT scan and sonography is done. We received hand-written report for CT scan, actual report will follow soon. Her current creatinine is 5.7. It is increased because there was complete blockage for 24 hours and after that they could fit only one stent.

Doctor's analysis based on CT scan outcome:
--------------------------------------------
- There is a moderate bulge on right kidney because there is no stent on right side. This budge will come under control after fitting stent there.
- Stent on right side kidney will be placed on Tuesday early morning
- Both ureters are clear, no strictured part identified, no swelling identified on ureters. no blockage at all
- Doctor discussed this with other doctors but none of them have any idea on why my mother is not able to pass urine without stents.
- They said, this is one of the case where they have no clue on why she is not passing urine without stent but passing urine with stent. This behavior rules out the possibility of kidney damage because she is able to pass urine with stents and she is healthy and fit when stents are there. CT scan indicates no issues with ureter. So they do not know the exact reason.
- They found a bulge near pelvis/ urethra/ cervix. They will do sonography again with anesthesia when they fit the other stent. they have called gynecologist to check that bulge and another urologist to get his opinion. They consulted other doctors too but none of them seems to have an idea on why she is not able to pass urine without stents.

Hand written CT Scan report is as mentioned below -->
-----------------------------------------------------
B/L small pleural effusion (free) and passive basal collapse. Few focal fibrotic parenchymal band in both lower lung

Right kidney appear bulky and moderate hydronephrosis and HU for entireily. No ay calculas noted in right kidney. Prominent perinephric fat stranding noted.

DJ stenting noted in left kidney - results decompression.

Uterus body is normal in size and appearance. The cervix appear bulky and hypoattenuating in pelvis.

Few enlarged Retroperitoneal LNs

Important - Bulky cervix and right sided hydronephrosis and HU (possibility of cervical neoplastic process ruled out)


---------------------------------------------------------------------

your analysis and suggestions are greatly appreciated. Thanks for your responses!
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Follow up: Dr. Manuel C See IV 6 minutes later
Forgot to mention that CT scan outcome is hand written so I was not able to spell all words correctly. I tried my best to write the hand written report. Sorry for the confusion and hopefully you will figure out mis-spelled words.
doctor
Answered by Dr. Manuel C See IV 36 minutes later
Brief Answer:
Nephrostomy tube placement can be a better option.

Detailed Answer:
thank you for the additional Information.

Based on the CT SCAN findings I can say that the obstruction maybe due to external compression of the enlarged lymph nodes or the cervix or both. Your mother might need to do a PAPs smear and possibly a cervical biopsy to rule out cervical cancer. Cervical cancer is quite common to cause obstruction in the ureters. It is imperative to relieve the obstruction in the kidneys by stent or a nephrostomy tube which is a tube that drains directly to the kidneys. They can do a RGP (retrograde pyelogram) during the stent insertion to determine the exact level of obstruction in the ureter. Stent failure is very common for obstruction caused by external compression and nephrostomy tube placement has better durable outcomes and much easier to replace than an internal stent.

Continuous blockage of the kidney will definitely cause damage to the kidneys and should be decompressed ASAP. If a stent cannot be placed because of the blockage then discuss the possibility of a nephrostomy tube in the right side. The blockage of the kidneys is a secondary problem and the primary problem should also be addressed (cervix and/or lymph nodes in the retroperitoneum).

I wish the best of health to your mother and I hope everything will be okay.

Regards,

Manuel C. See IV, M.D. DPBU FPUA

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Manuel C See IV 4 hours later
Thank you Doctor. I discussed your suggestions with my doctor, he is going to perform similar tests as you suggested.

I have attached a CT scan report done in April 2014 and the CT scan report (hand written) done in Aug 2014 for you to compare. Kindly let me know your analysis and if the comparison changes your opinion.

Gynecologist asked my mother all questions related to symptoms of cervical cancer. My mother provided all negative answers to her questions. I understand the symptoms may not be visible and actual test may relieve her medical condition.

Doctor suggested that if they cannot insert stent from bottom then he will try to insert stent from kidney (top). I may have mis-understood this.

Please let me know if you cannot access report I have uploaded to my profile. Printed report is from April 2014 and hand written report is from Aug-11-2014
doctor
Answered by Dr. Manuel C See IV 27 minutes later
Brief Answer:
I can't see attached results.

Detailed Answer:
I'm sorry I can't see the attached results. Yes in terms of cervical cancer the gynecologist needs to do a speculum examination and possibly biopsy the cervix. Yes a nephrostomy is an external stent and is done if an internal cannot be placed.

I'll await the uploaded results

Regards, Manuel C. See IV, M.D. DPBU FPUA

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Manuel C See IV 7 minutes later
Sorry for the confusion. I had uploaded reports to my profile. Please check now, reports are now uploaded to this discussion thread
doctor
Answered by Dr. Manuel C See IV 3 hours later
Brief Answer:
Continue with planned procedures.

Detailed Answer:
Thank you for providing the Ct scan reports.

In the ct scan done last April there was I mention of any cervical mass or cervical fullness as compared with the ct scan done recently. I believe and RGP would provide better information since it will done in a dynamic fashion during the stent placement.

It is very hard to conclude anything since there was no contrast used on both CT scans ( due to the elevated creatinine of your mother ). I would still consider to continue with the planned stent insertion possible nephrostomy tube insertion and investigation of your mothers cervix.

I hope I have succeeded in providing the information you were looking for. Please feel free to write back to me for any further clarifications at: http://www.HealthcareMagic.com/doctors/dr-manuel-c-see-iv/66014 I would gladly help you. Best wishes.

Regards, Manuel C. See IV, M.D. DPBU FPUA

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Manuel C See IV 14 hours later
Doctor inserted stent on right kidney from back. He was not able to insert stent thru usual process.

Gynecologist examined my mother and said there are 90% chance of cervical cancer. Cervical biopsy test results will be available in 2-3 days. Gynecologist scheduled an appointment with oncologist. We are not sure of the severity of cancer. I just pray to God that she is at preliminary stage. I have attached notes from gynecologist for your reference.

Could you please give your opinion on the notes from Gynecologist.
doctor
Answered by Dr. Manuel C See IV 2 hours later
Brief Answer:
I'm sorry to hear about the cancer.

Detailed Answer:
I'm glad that your Urologist was able to successfully insert a nephrostomy tube to relieve the obstruction. Based on the notes of the gynecologist your mother has cervical cancer (ulcerative feel ...) and since it is fixed to the surrounding structures then it might also be locally advanced. I'm sure the gynecologist would give you treatment options when the tissue sample results comes out and options would depend on the stage of the disease.

Surgery and radiation treatment are used to treat cervical cancer with good outcomes, again depending on the stage and grade of the cancer. In relation to the stent and nephrostomy tube once the cervical cancer is treated and the compression/obstruction is gone then your mother may pass urine on her own and we can already remove the tubes.

I hope I have succeeded in providing the information you were looking for. Please feel free to write back to me for any further clarifications at: http://www.HealthcareMagic.com/doctors/dr-manuel-c-see-iv/66014 I would gladly help you. Best wishes.

Regards, Manuel C. See IV, M.D. DPBU FPUA

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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