Evaluation of the patient with suspected ureteral obstruction begins with a complete history and physical examination. Laboratory evaluation includes a CBC, serum electrolytes, BUN, creatinine, and urine culture. Since patients with ureteral obstruction may require the placement of percutaneous nephrostomy tubes, coagulation parameters should be routinely measured if obstruction is suspected. It is of the utmost importance to rule out the presence of concomitant urinary tract infection. Fever and flank pain together with leukocytosis and pyuria suggest urosepsis, a urologic emergency. Without prompt endoscopic or percutaneous decompression, obstructed urosepsis is a potentially lethal condition. Upper tract imaging should be performed in all cases of suspected ureteral obstruction. Available options include intravenous pyelography, retrograde pyelography, antegrade pyelography, renal ul-trasonography, radionuclide renography, and CT or MRI of the abdomen and pelvis (Fig. 13.4). These studies can confirm the presence and site of obstruction and may also provide clues as to the etiology. In this regard, CT and MRI provide the best anatomic detail of the retroperitoneum and pelvis (Fig. 13.5). Upper tract imaging can also establish the presence and severity of obstructive uropathy. The finding of small atrophic kidneys with marked cortical thinning indicates chronic obstruction (Fig. 13.6). Renal deterioration secondary to chronic obstruction is unlikely to improve with decompression; therefore, intervention is reserved for infected renal units (Logothetis et al. 2003).

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