What is the treatment for ureteral obstruction?

Treatment of Ureteral Obstruction

In cases of ureteral obstruction, urgent decompression via percutaneous nephrostomy (PCN) or retrograde ureteral stenting is strongly recommended, especially when accompanied by sepsis and/or anuria. 1

Initial Management Based on Clinical Presentation

Emergency Decompression for Sepsis or Anuria

• For patients with sepsis and/or anuria due to obstructed kidney, urgent decompression of the collecting system is mandatory 1
• Urine should be collected for antibiogram testing before and after decompression 1
• Antibiotics should be given immediately and regimen adjusted following antibiogram results 1
• Intensive care may be necessary in severe cases 1

Pain Management for Renal Colic

• NSAIDs (diclofenac, ibuprofen, metamizole) are first-line treatment for renal colic 1
• NSAIDs reduce the need for additional analgesia compared to opioids 1
• Use the lowest effective dose of NSAIDs to minimize cardiovascular and gastrointestinal risks 1
• Opioids are recommended as second-choice analgesics when NSAIDs are contraindicated 1
• If opioids are required, agents other than pethidine (such as hydromorphone, pentazocine, or tramadol) are preferred 1

Treatment Options Based on Etiology

Ureteral Stones

• Medical expulsive therapy (MET) with alpha-blockers (such as tamsulosin) is effective for stones amenable to conservative management, particularly for stones >5mm in the distal ureter 1, 2
• Tamsulosin works by blocking alpha-1 adrenoceptors, causing smooth muscle relaxation in the prostate and bladder neck, improving urine flow 2
• For uric acid stones, oral chemolysis with citrate or sodium bicarbonate (pH 7.0-7.2) can dissolve stones with a success rate of 80.5% 1

Malignant Ureteral Obstruction

• For obstruction due to advanced malignancies (e.g., cervical carcinoma), retrograde ureteral stenting, PCN, or percutaneous antegrade ureteral stenting are all appropriate options 1
• PCN decompression as primary management of ureteral injuries results in decreased need for reoperation and decreased morbidity rates 1
• PCN can provide access for definitive treatment of ureteral strictures and leaks 1

Ureteral Injury/Leak

• For ureteral leaks after surgery, retrograde ureteral stenting, PCN, percutaneous antegrade ureteral stenting, or PCN followed by delayed surgery are all appropriate options 1
• Following cesarean section, 75% of ureteral injuries can be successfully managed with percutaneous management utilizing ureteral stent placement with or without ureteral dilatation 1
• If initial retrograde stenting fails, interval placement of a PCN should be considered 1

Choosing Between PCN and Retrograde Ureteral Stenting

Indications for PCN

• Sepsis with obstruction 1
• Failed retrograde stenting 1
• Ureteric orifice occlusion due to tumor 1
• Tight stricture close to the uretero-vesical junction 1
• Extrinsic compression or ureteral obstruction length >3 cm in emergent settings 1

Indications for Retrograde Ureteral Stenting

• First-line therapy for management of ureteral obstruction caused by gynecologic malignancies 1
• Shorter procedural and fluoroscopy times compared to PCN 3
• Less invasive approach 1

Special Considerations

Pregnancy

• For pregnant patients with obstruction, ultrasound is strongly recommended as first-line imaging 1
• Both retrograde ureteral stenting and PCN are appropriate for pregnant patients with flank pain, fever, and hydronephrosis 1
• Minimizing radiation exposure is critical - placement of an antegrade ureteral stent requires increased fluoroscopy time and radiation dose to the fetus 1

Genitourinary Tuberculosis

• Renal tuberculosis is treated primarily with medical therapy, and a 6-month regimen is recommended 1
• If ureteral obstruction occurs, procedures to relieve the obstruction are indicated 1
• In cases of hydronephrosis and progressive renal insufficiency due to obstruction, renal drainage by stenting or nephrostomy is recommended 1
• The efficacy of corticosteroids for ureteric stenosis in this setting is unclear 1

Management of Stent-Related Symptoms

• Approximately 80% of patients with ureteral stents experience bothersome urinary symptoms and pain 4
• A multimodal approach using alpha-blockers, anticholinergic medications, and anti-inflammatory medications is most effective for managing stent discomfort 4

Pitfalls and Caveats

• NSAIDs may impact renal function in patients with low glomerular filtration rate 1
• Postprocedural bacteremia and sepsis are common when infected urinary tracts are drained 1
• Preprocedural antibiotics are recommended when urosepsis is suspected or known to be present 1
• Third-generation cephalosporin ceftazidime has shown superiority over fluoroquinolone ciprofloxacin in both clinical and microbiological cure rates 1
• PCN has been shown to improve early and long-term cure rates compared to ureteral stent in cases of infection 1