Obstructive Hydronephrosis

Produced by Aberrant Blood Vessels and Diagnosed by Intravenous Uroqraphy!

JACOB ABOWITZ, M.D.2
Los Angeles, Calif.

BE RRANT blood vessels of the kidney aberrant blood vessels has been facilitated
A are not uncommon, and very often
they produce obstructive hydronephrosis.
by the introduction and subsequent im-
provement of intravenous pyelography,
Until the year 1906, the presence of these so that at present the preoperative diag-
blood vessels was of academic interest only, nosis is a common occurrence.
since they were usually found at autopsy Intravenous Pyelography versus Retro-
or at the surgical table. In that year, the grade Pyelography: The intravenous
cystoscopic method of pyelography was method of urography lends itself admirably

Fig. 1. Diagrammatic illustrations of hydronephrotic kidney caused (A) by a large anomalous artery crossing
the upper ureter and (B) by either an adhesive band or obliterated blood vessel.

introduced, that is, radiography of the to the investigation and to the establish-
renal pelvis and ureters after the injection ment of the diagnosis of obstructive hydro-
of a radiopaque solution (such as sodium nephrosis produced either by aberrant
or potassium iodide), with the aid of the blood vessels or by any other cause. With
cystoscope and ureteral catheter. Shortly this method, we usually obtain roentgeno-
after that, Ekehom suggested the pos- grams demonstrating the true shape, size,
siblity that aberrant blood vessels of the and position, as well as function, of the
kidney might in some instances produce kidney, in contradistinction to the retro-
obstructive hydronephrosis. However, grade or cystoscopic method, in which the
the preoperative diagnosis in such. cases urinary tract may be either under- or over-
was made only rarely. Recently, the diag- distended, unless the pressure of the in-
nosis of obstructive hydronephrosis due to jected fluid is carefully regulated. The
intravenous method causes practically no
1 Accepted for publication in February 1946.
2 Director, Department of Roentgenology, Cedars of
disturbance of the normal physiologic func-
Lebanon Hospital, Los Angeles, Calif. tion of the kidney and does not produce
33
84 JACOB ABOWITZ January 1947

spasm of the urinary tract nor temporary at the lower pole of the kidney, situated
anuria, conditions often encountered with anterior to the ureteropelvic junction, may
the instrumentation of cystoscopic exami- produce obstruction (Fig. 1). Normally,
nation. the kidney is supplied by one renal artery,
Prevalence of Aberrant Blood Vessels: a branch of the abdominal aorta. It usu-
The presence of aberrant blood vessels is ally enters the kidney through the hilum,
so common that Anson, Richardson, and where it breaks up into smaller blood ves-
Minear, in a careful dissection of two hun- sels, to form the complex renal blood supply.
dred cadavers, found only 35 per cent with Occasionally, the renal artery branches out,
normal blood vessels supplying both kid- fan-like, before it enters the hilum, and one

Fig. 2. Break in continuity of the ureter at the ureteropelvic junction produced by an aberrant
blood vessel, causing obstructive hydronephrosis.

neys; the remainder had anomalous vessels or more of the lower branches of this fan
of either one or both organs. The same attaches itself to the lower pole of the kid-
authors quoted Jeidell (1911): ney, forming an aberrant blood vessel.
"So complex is the vascular network in the meso-
Often, an independent branch of a lower
nephric area of the embryo, that one is surprised segment of the abdominal aorta is found
not in encountering examples of supernumerary supplying the lower pole of the kidney.
vessels in the adult, but rather in finding any case Occasionally, instead of a blood vessel, we
-in which a single artery supplies each kidney." find at operation a narrow band crossing
Fortunately, not all aberrant blood ves- the ureter, which microscopic analysis
sels produce obstruction; more than half proves to be an obliterated blood vessel.
are found at the upper pole of the kidney, The question always presents itself:
above the hilum, and these obviously Why do symptoms of hydronephrosis occur
could not produce ureteral obstruction. during adult life, and only rarely in child-
Only those blood vessels which are found hood, in spite of the fact that the aberrant
Vol. 48 OBSTRUCTIVE HYDRONEPHROSIS 35

blood vessel is a congenital anomaly? The

answer, I believe, lies in the fact that the
urinary tract and the blood vessels belong
to two quite distinct sets of organs,
each undergoing different characteristic
changes during life. The blood vessel may
lose some of its elasticity, while the kidney
may move down to a lower position, there-
by falling over, so to say, a stretched blood
vessel, consequently compressing the ureter.
Importance of a Complete Diagnosis: In
the present state of development of diag-
nostic roentgenology, it is not enough for
the roentgenologist to consider the finding
of hydronephrosis a complete diagnosis;
he must endeavor to establish the cause,
whether obstruction or infection, and if ob-
struction, what kind and where, so that
the proper treatment may be instituted.
Roentgen Findings: The urographic find-
ings in hydronephrosis, for the purposes of
this presentation, may be divided into two
groups: (1) general findings common to
hydronephrosis, regardless of cause; (2)
specific findings characteristic of hydro-
nephrosis produced by aberrant blood Fig. 3. Square renal pelvis, with the ureter inserted
vessels in the angle of the square. Note also the constriction
at the ureteropelvic junction which, at operation,
(1) The first group of findings as seen on proved to be due to an aberrant blood vessel.
the x-ray film are as follows:
(a) Blunting, enlargement or spherical urinary stasis increases the dilatation of
dilatation of the minor calices; abbrevia- the renal pelvis, forms precipitates of
tion or dilatation of the major calices; dila- urinary salts which aid in the formation of
tation of the renal pelvis. The degree of renal calculi, and is responsible for the sub-
involvement of these structures depends jective symptoms. I t also predisposes the
on the severity and duration of the case. kidney to infection.
(b) Increased radiopacity of the shadow (d) The ureter is usually empty below
of the hydronephrotic pelvis produced by the point of obstruction.
the excreted chemical 3 on the affected side, (2) The second group of roentgeno-
as compared with the radiopacity of the graphic findings are those due to aberrant
pelvis of the opposite, unaffected side. blood vessels:
This increased radiopacity is due to the (a) It is obvious that the aberrant blood
larger volume of the affected pelvis. vessel producing the obstruction is not
(c) The normal renal pelvis, as demon- visible on the film, as it is practically of the
strated on the roentgenogram, is usually same density as the surrounding tissue, so
empty when the patient is in the upright far as x-rays are concerned. One sees,
posture. With ureteral obstruction, the however, on the intravenous urogram,
pelvis is either partly or completely filled, when the pelvis and ureter are filled with
even with the patient upright, producing a the excreted radiopaque solution, a break
urinary stasis above the obstruction. This in continuity, or a sharp narrow line at the
8 Disodium N-methyl-3,5-diiodochelidamate (Neo-
ureteropelvic junction crossing the ureter
iopax). (Fig. 2). This sharp line is the constric-
36 JACOB ABOWITZ January 1947

Fig. 4. "Derby-hat appearance" of the pelvis. A double constriction is present at the uretero-
pelvic junction, by two blood vessels.

tion produced by the aberrant blood ves- assumes a "derby-hat appearance," with
sel. Occasionally, more than one such the ureter in the center of the crown.
line is present, probably due to several The pelvis retains this shape, even when it
branches of the blood vessel crossing the reaches its maximum dilatation (Fig. 4).
ureter. Often, the constriction is hidden (d) The minor calices become affected at
behind the renal pelvis, in which event the a much later period, when the pelvis is al-
distal end of the pelvis may form a small ready perceptibly involved. This is true
knob-like dilatation. in all high ureteral obstructions.
(b) As the obstruction develops, either (e) On several occasions at operation, in-
insidiously or rapidly, a characteristic stead of aberrant blood vessels, adhesions
change is found in the outline of the renal or adhesive bands were found crossing the
pelvis. Normally, the pelvis is funnel- ureteropelvic junction. Microscopic study
shaped, tapering down gradually to meet of these adhesions showed obliterated blood
the ureter. When an aberrant blood ves- vessels among them.
sel crosses it, the pelvis forms a right angle
CONCLUSION
or a square, the mesial border of the pelvis
The value of demonstrating the change
is parallel and adjacent to the edge of the
in appearance of the renal pelvis to square
psoas muscle, the ureter is seen at the
or derby-hat shape lies in the fact that
lower mesial comer of the square. The
from this alone a correct diagnosis can be
proximal end of the ureter, in this case,
made, even when the obstructive line in
does not flare out to meet the pelvis, but
the ureter produced by the aberrant blood
is of uniform caliber throughout, like a
vessel is hidden behind the pelvis and is not
drinking straw (Fig. 3).
visualized on the film.
(c) As the hydronephrosis progresses, the 615 S: Bonnie Brae St.
pelvis loses its angular or square shape and Los Angeles 5, Calif.