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Case 175

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Female patient, 32 years old, complains of chronic back pain, moderate and intermittent. Denies hematuria or urinary volume changes, smoking, previous surgeries and use of medications. Refers history of recurrent urinary infections. On examination the patient was in good general condition, no fever, mild pain on palpation of the left lower back. Blood pressure: 118/80 mmHg. Have normal values of urea, creatinine and clearance renal.Solicitada ultrasonography (USG) of the urinary tract - which showed hydronephrosis of the left kidney - and, later, computed tomography (CT).

Based on the clinical picture and the data obtained, what is the most likely obstructive disorder?

a) Retroperitoneal fibrosis

25%

b) Nephrolithiasis

25%

c) Congenital obstruction of the ureteropelvic junction

25%

d) Urothelial tumor of the renal pelvis or ureter

25%
   

Image analysis

Images 1 and 2: Computed tomography - 3D Reconstruction: Left kidney presenting significant dilatation of the pelvis (in green); ipsilateral ureter not opacified (red arrows). Right kidney with tomographic characteristics within normal limits. Right ureter demonstrating physiological tortuosities (arrows in blue).

 

Images 3 and 4: Computed tomography after left pyeloplasty - 3D Reconstruction. Left kidney with dimensional reduction in a comparative study with the examination in the preoperative phase. Left ureter properly opacified, showing size and path within normal limits.

Highlights

- Congenital obstruction of the ureteropelvic junction consists of the blockage of the urinary flow from the renal pelvis to the ureter.

- The main cause is interruption in the development of circular muscles of the ureteropelvic junction and / or a change in the composition of the collagen fibers in and around the muscle cells.

- Although congenital, the picture may become clinically apparent in adulthood and the diagnosis is often incidental, during the investigation of recurrent urinary tract infections and intermittent lower abdomen pain.

- The main finding that suggests the diagnosis is hydronephrosis on the ultrasound. CT is used for better programming of the surgery in cases of complex deformity.

- Management is conservative in asymptomatic patients with preserved renal function. When there is surgical indication, the standard procedure for correction of the obstruction is the pyeloplasty.

References

- Goldman L,  Ausiello D. Cecil: Tratado de Medicina Interna. 2010 23 ªEdição. Rio de Janeiro:ELSEVIER, 2010.

- Campbell W. Urology 10ª Ed, vol II. Philadelphia: Saunders Elsevier, 2012.

- Laurence S Baskin.Congenitalureteropelvic junction obstruction. Uptodate, 2014. Available at: http://www.uptodate.com/contents/congenital-ureteropelvic-juncion-obstruction

- Jerome P Richie, MD. Malignancies of the renal pelvis and ureter. Uptodate, 2014. Available at: http://www.uptodate.com/contents/malignancies-renal-pelvis-ureter

Author

Ana Luiza Mattos Tavares, 5th year medical student in UFMG.

Email: analuizamt[at]gmail.com

Supervisors

Carlos Eduardo Corradi Fonseca, urologist, professor of the Surgery Department of UFMG's School of Medicine.

E-mail: carloscorradi[at]terra.com.br

Kátia de Paula Farah, nephrologist, professor of the Clinic Department of UFMG's School of Medicine.

E-mail: katiafarah[at]gmail.com

Reviewers

Ana Júlia Furbino Dias Bicalho, Fábio Mitsuhiro Satake, Luanna da Silva Monteiro and Viviane Parisotto.

Translated by

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. Email: barbara.bragaglia[at]ufmg.br

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