Hydronephrosis

HYDRONEPHROSIS &
VESICOURETERAL
REFLUX
Dr. Farhanul Huda
Associate Professor
Dept. Of Surgery
AIIMS
Rishikesh
HYDRONEPHROSIS
Hydronephrosis is a condition where one or both
kidneys become stretched and as the result of a build-up of urine inside them.
Itcan affect people of any age and is sometimes spotted in unborn

babies during routine pregnancy ultrasound scans. This is known as
antenatal hydronephrosis.
classification
Fetal hydronephrosis
Mild (only renal pelvis): 4-7 mm in the 2nd trimester; 7-9 mm in the 3rd.
Moderate (pelvis and calyces): 8-10 mm in the 2nd trimester; 10-15
mm in the 3rd. Severe (cortical thinning): >10 mm in the 2nd trimester;
>15 mm in the 3rd
According to grade
Hydronephrosis can vary in severity. Typically, your doctor will describe
your child's hydronephrosis as mild, moderate or severe. Sometimes
hydronephrosis is given a grade of 1, 2, 3 or 4, with 1 representing
very minimal dilation and 4 representing severe dilation.
Causes of U/L obstruction
• Extramural obstruction
■ Tumour from adjacent structures, e.g. carcinoma of the
cervix, prostate, rectum, colon or caecum
■ Idiopathic retroperitoneal fibrosis
■ Retrocaval ureter
What is the differential diagnosis?
• Physiologic hydronephrosis.
• Dilation of the upper urinary tracts occurs by the 7th week of
gestation and may persist for 6 weeks postpartum.
• Results from both hormonal and mechanical factors.
• Ureteral dilation is more pronounced on the right side because
of dextrorotation of the uterus, whereas the left ureter is more
protected from compression by the gas filled sigmoid colon.
• How do you distinguish physiologic hydronephrosis from
intrinsic obstruction due to distal ureteral stone disease?
• Physiological hydronephrosis typically is more on the right side

and generally terminates at the pelvic brim.
• If the hydroureteronephrosis extends below the pelvic brim,
distal ureteral obstruction should be considered.
How is this managed?
• Analgesia
• Positioning the patient on her left side.
• Ureteral stent or nephrostomy tube
• The flank pain resolves with conservative measures and you
see the patient in clinic 2 weeks later. Her urinalysis (UA) shows
bacteriuria, but she is asymptomatic.
Should this be treated?

Should this be treated?
• Because of the risk of acute pyelonephritis.
• The rate of progression of asymptomatic bacteriuria to
symptomatic infection is 3‐4 times higher during pregnancy.
Introduction
• Common clinical condition.
• Defined as distention of the renal calyces and pelvis with urine as a
result of obstruction of the outflow of urine.
• Can be physiologic or pathologic, acute or chronic, unilateral or
bilateral.
• Obstructive uropathy ?
• Functional or anatomic obstruction of urinary flow at any level of the
urinary tract.
• Obstructive nephropathy ?
• When the obstruction causes functional or anatomic renal damage.
Pathophysiology
Interruption in the flow of urine
Increased ureteral pressure
Decreased GFR
• This decline of GFR can persist for weeks after relief of
obstruction.
• Decreased function of the nephrons.
• The extent of functional insult is directly related to the duration
and extent of the obstruction.
• Brief obstruction- reversible functional changes.
• Chronic obstruction - profound tubular atrophy and permanent
nephron loss.
• Intramural obstruction
■ Congenital stenosis, PUJO
■ Ureterocele and congenital small ureteric orifice
■ Stricture
■ Neoplasm of the ureter or bladder cancer involving the
ureteric orifice
• Intraluminal obstruction
■ Calculus in the pelvis or ureter
■ Sloughed papilla in papillary necrosis due to?------
Causes of B/L Hydronephrosis
• congenital:
– posterior urethral valves;
– urethral atresia;
• acquired:
– benign prostatic enlargement or carcinoma of the prostate;
– postoperative bladder neck scarring;
– urethral stricture;
– phimosis.
Clinical features
• Mild pain or dull aching in the loin.
• Palpable kidney
• New onset HTN
• Recurrent UTIs
• Attacks of acute renal colic may occur with no palpable swelling.
• Intermittent hydronephrosis (Dietl’s crisis).
A swelling in the loin is associated with acute renal pain. Some
hours later the pain is relieved and the swelling disappears when
a large volume of urine is passed.
Investigations
• urine analysis
• Assesment of renal function
• USG
• Colour Doppler USG
• CT urography
• MR urography
• IVP
• Retrograde pyelography
• Isotope renography
• Very occasionally, a Whitaker test is indicated. A percutaneous puncture of the kidney is
made through the loin and fluid is infused at a constant rate with monitoring of intrapelvic
pressure.
Treatment
1. Pain management.
2. Renal drainage – stenting/nephrostomy – why?
3. Treat the cause
4. Anderson-Hynes pyeloplasty.
5. Endoscopic pyelolysis
VESICOURETERAL REFLUX
INTRODUCTION
• Characterized by the retrograde flow of urine from the bladder
to the kidneys.
• VUR may be associated with (UTI), HDN and abnormal kidney
development (renal dysplasia).
• Increased risk for pyelonephritis, hypertension, and
progressive renal failure.
• Early diagnosis and vigilant monitoring of VUR are the
cornerstones of management.
CAUSES
Primary causes
• Short or absent intravesical ureter
• Absence of adequate detrusor backing
• Lateral displacement of the ureteral orifice
• Paraureteral (Hutch) diverticulum
Secondary causes
• Cystitis or UTI
• Bladder outlet obstruction
• Neurogenic bladder
• Detrusor instability
Pathophysiology
• Ureter inserts into the trigone.
• The intramural portion of the ureter courses into the bladder
wall at an oblique angle.
• This intramural tunnel length–to–ureteral diameter ratio is 5:1.
• As the bladder fills with urine and the bladder wall distends and
thins, the intramural portion of the ureter also stretches, thins
out, and becomes compressed against the detrusor backing.
• This functions as a flap-valve mechanism and prevents urinary
reflux.
Pathophysiology
• A short intramural tunnel results in a malfunctioning flap-valve
mechanism and VUR.
• Reflux of infected urine is responsible for the renal damage.
• bacterial endotoxins leads to release of oxygen free radicals.
• These oxygen free radicals result in fibrosis and scarring of the
affected renal parenchyma.
Clinical features
• No specific signs or symptoms unless complicated by UTI.
• LUTS.
• Palpable kidney.
• New onset HTN.
• Renal failure.
Workup VUR
Lab studies
• Urinalysis and urine culture.
• RFT.
• Serum electrolytes
Imaging studies
• VCUG/radionuclear cystouretherography
• USG
• Nuclear scan
• Urodynamic studies
• Cystoscopy
Treatment
• Medical treatment
• Surgical treatment
• Surveillance
Medical management
• Administering long-term suppressive antibiotics
• Correcting the underlying voiding dysfunction (if present)
• Conducting follow-up radiographic studies (eg, VCUG, nuclear
cystography, DMSA scan) at regular intervals
Surgical treatment
• Grade III or more reflux.
• Failure of medical management.
• Ureteral reimplantation
• Endoscopic treatment:
• The principle of the procedure is to inject, under cystoscopic
guidance, a biocompatible bulking agent underneath the
intravesical portion of the ureter in a submucosal location.
• The bulking agent elevates the ureteral orifice and distal ureter in
such a way that the lumen is narrowed, preventing regurgitation of
urine up the ureter but still allowing its antegrade flow.
A 50 year old female is admitted with abdominal pain
and anuria. Radiological studies reveal bilateral
impacted ureteric stones with hydronephrosis. Urine
analysis showed RBCs with pus cells in urine. Serum
creatinine level was 16 mg / dl and blood urea level
was 200 mmol/L; which of the following should be the
immediate treatment.
a. Lithotripsy
b. Ureteroscopic removal of stones
c. ‘J’ stent drainage
d. Hemodialysis

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HYDRONEPHROSIS &

Itcan affect people of any age and is sometimes spotted in unborn

• Physiological hydronephrosis typically is more on the right side

Should this be treated?

Interruption in the flow of urine

Increased ureteral pressure

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