Hydronephrosis Dr Lokku


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Hydronephrosis Dr Lokku

  1. 1. HYDRONEPHROSIS Dr.Logarangan Reg#08LO260716MU WEST INDIES
  2. 2. DEFINITION: <ul><ul><li>The dilation of the renal pelvis and calyces. </li></ul></ul><ul><ul><li>May be considered a physiologic response to the interruption of urine. </li></ul></ul><ul><ul><li>Not always caused by obstruction. </li></ul></ul>
  3. 4. INCIDENCE: <ul><li>Pre-natal ultrasound </li></ul><ul><ul><li>detects fetal anomaly in 1% of pregnancies, of which 20-30% are genitourinary in origin and 50% manifest as hydronephrosis </li></ul></ul>
  4. 5. CAUSES: <ul><li>Can be intrinsic, extrinsic or functional and can be classified as to level within the urinary tract </li></ul><ul><li>Ureter </li></ul><ul><ul><li>Intrinsic </li></ul></ul><ul><ul><ul><li>congenital ureteropelvic junction stricture </li></ul></ul></ul><ul><ul><ul><li>papillary necrosis </li></ul></ul></ul><ul><ul><ul><li>iatrogenic </li></ul></ul></ul><ul><ul><ul><li>blood clot </li></ul></ul></ul><ul><ul><ul><li>ureteral tumor </li></ul></ul></ul>
  5. 6. CAUSES: <ul><li>Extrinsic </li></ul><ul><ul><li>retroperitoneal cancer </li></ul></ul><ul><ul><li>aortic aneurysm </li></ul></ul><ul><ul><li>retrocaval ureter </li></ul></ul><ul><ul><li>inflammatory bowel disease </li></ul></ul><ul><ul><li>retroperitoneal hemorrhage </li></ul></ul><ul><ul><li>lymphocele </li></ul></ul>
  6. 7. CAUSES: <ul><ul><li>Functional </li></ul></ul><ul><ul><ul><li>gram-negative infection </li></ul></ul></ul><ul><ul><ul><li>neurogenic bladder </li></ul></ul></ul><ul><li>Bladder </li></ul><ul><ul><li>Intrinsic </li></ul></ul><ul><ul><ul><li>calculi </li></ul></ul></ul><ul><ul><ul><li>bladder neck contracture </li></ul></ul></ul><ul><ul><li>Functional </li></ul></ul><ul><ul><ul><li>VUR </li></ul></ul></ul><ul><ul><ul><li>neurogenic bladder </li></ul></ul></ul>
  7. 8. CAUSES: <ul><li>Urethra </li></ul><ul><ul><li>Intrinsic </li></ul></ul><ul><ul><ul><li>urethral stricture </li></ul></ul></ul><ul><ul><li>Extrinsic </li></ul></ul><ul><ul><ul><li>BPH </li></ul></ul></ul>
  8. 9. ANTENATAL PERIOD <ul><li>The most common cause is physiologic dilation. </li></ul><ul><li>Metanephric urine production begins at 8 weeks, even before ureteral canalization is complete. </li></ul><ul><li>Transient obstruction with hydronephrosis occurs. </li></ul>
  10. 13. PATHOPHYSIOLOGY: <ul><li>Anatomic and functional processes interrupts the flow of urine. </li></ul><ul><li>There is a rise in ureteral pressure causing stretching and dilation; if pressures continue to rise, leads to decline in renal blood flow and GFR. </li></ul><ul><li>When significant obstruction is persistent, it affects nephrogenic tissue and results in varying degrees of cystic dysplasia and renal impairment. </li></ul>
  12. 17. MOST COMMON CAUSES IN NEONATES: <ul><li>Ureteropelvic Junction Obstruction </li></ul><ul><li>Ureterovesical Junction Obstruction </li></ul><ul><li>Posterior Urethral Valves </li></ul><ul><li>Eagle-Barrett Syndrome (a.k.a. Prune Belly Syndrome) </li></ul><ul><li>Vesicoureteral Reflux </li></ul><ul><li>Ureterocele </li></ul>
  13. 18. URETEROPELVIC JUNCTION OBSTRUCTION <ul><li>UPJ is the most common cause of hydronephrosis in children. </li></ul><ul><li>May be the result of incomplete racanalizaton of the proximal ureter, abnormal development of ureteral musculature, abnormal peristalsis, ureteral valves or polyps. </li></ul><ul><li>Causes functional obstruction. </li></ul>
  14. 19. URETEROPELVIC JUNCTION OBSTRUCTION: <ul><li>Male:female ratio is 2:1. </li></ul><ul><li>Prior to prenatal screening, about 25% were diagnosed in the first year of life. </li></ul><ul><li>Decreasing frequency with age. </li></ul>
  15. 20. CLINICAL DETAILS OF UPJ OBSTRUCTION: <ul><li>Anatomically indistinct segment of the upper collecting system where the renal pelvis funnels into the ureter. </li></ul><ul><li>In 25-40% of kidneys, a supernumerary artery crosses the collecting system on its course into the kidney’s lower pole causing mechanical obstruction. </li></ul><ul><li>Occurs more often on the left side than on the right with a 3:2 ratio. </li></ul>
  16. 22. OTHER FACTS ON UPJ: <ul><li>Often associated with other congenital renal anomalies </li></ul><ul><ul><li>ectopic or horseshoe kidneys </li></ul></ul><ul><ul><li>duplication of the collecting system </li></ul></ul><ul><ul><li>contralateral renal dysplasia </li></ul></ul><ul><ul><li>MCDK </li></ul></ul><ul><ul><li>renal agenesis </li></ul></ul><ul><ul><li>VUR (<40%), often low grade </li></ul></ul><ul><li>VATER Syndrome </li></ul>
  17. 23. DIAGNOSTIC MODALITY FOR UPJ: <ul><li>Ultrasonography is the initial modality of choice. </li></ul><ul><li>IVP </li></ul><ul><li>Retrograde pyelography </li></ul><ul><li>Radionuclide renogram </li></ul>
  18. 24. ASSESSMENTS ON UTS: <ul><li>Renal length/size </li></ul><ul><li>Degree of caliectasis and parenchymal thickness </li></ul><ul><li>Presence of ureteral dilatation </li></ul>
  20. 26. POSTERIOR URETHRAL VALVES <ul><li>Abnormal congenital mucosal folds that are thin membranes impeding bladder drainage. </li></ul><ul><li>Most common obstructive urethral lesion in male newborns found at the distal prostatic urethra. </li></ul><ul><li>Incidence is approx’ly 1 in 8,000 males. </li></ul><ul><li>Approx’ly 50% have reflux. </li></ul><ul><li>VCUG is the modality of choice. </li></ul>
  21. 27. RADIOGRAPHIC SIGNS OF PUV: <ul><li>distended prostatic urethra </li></ul><ul><li>valve leaflets </li></ul><ul><li>bladder and/or bladder neck hypertrophy </li></ul><ul><li>diverticula </li></ul><ul><li>narrow stream in the penile urethra </li></ul><ul><li>incomplete emptying of the bladder </li></ul>
  22. 29. TREATMENT OF PUV: <ul><li>Transurethral valve ablation, vesicostomy or upper tract diversion </li></ul><ul><li>Urethral stricture is a common complication </li></ul><ul><li>Fetal intervention carries a high risk with mortality rate of 43% </li></ul><ul><li>ESRD, renal insufficiency and chronic renal failure are long-term consequences </li></ul>
  23. 30. <ul><li>30% of boys with posterior urethral valves whose symptoms present in infancy are at risk for progressive renal insufficiency. </li></ul>
  24. 31. EAGLE-BARRETT SYNDROME <ul><li>More commonly known as Prune Belly Syndrome </li></ul><ul><li>Characterized by: </li></ul><ul><ul><li>deficiency of abdominal wall musculature </li></ul></ul><ul><ul><li>a dilated, non-obstructed urinary tract </li></ul></ul><ul><ul><li>bilateral cryptorchidism </li></ul></ul><ul><ul><li>talipes equinovarus and hip dislocation </li></ul></ul><ul><li>Incidence is 1/35-50,000 </li></ul><ul><li>>95% occur in males </li></ul>
  25. 34. <ul><li>Believed to be caused by in-utero urinary tract obstruction and a specific mesodermal injury between the 4th and 10th week of gestation. </li></ul><ul><li>Associated with renal dysplasia or agenesis. </li></ul><ul><li>Often presents with a large-capacity, poorly contractile bladder. </li></ul><ul><li>Heart, pulmonary, GI and orthopedic anomalies occur in a large percentage of PBS patients. </li></ul>
  26. 36. MANAGEMENT: <ul><li>Neonatal Period </li></ul><ul><ul><li>Optimize urinary tract drainage </li></ul></ul><ul><ul><li>Monitor and treat renal insufficiency </li></ul></ul><ul><ul><li>Antibiotic prophylaxis if reflux is present </li></ul></ul><ul><li>Children </li></ul><ul><ul><li>Surgical repair of reflux </li></ul></ul><ul><ul><li>Orchiopexy </li></ul></ul><ul><ul><li>Reconstruction of the abdominal wall </li></ul></ul><ul><ul><li>Renal transplant </li></ul></ul>
  27. 37. VESICOURETERAL REFLUX <ul><li>Retrograde propulsion of urine into the upper urinary tract during bladder contraction. </li></ul><ul><li>Primary reflux is caused by attenuation of the trigone and the contiguous intravesical ureteral musculature. </li></ul><ul><li>May be caused by the ectopic insertion of the ureter into the bladder wall resulting in a shorter intravesicular ureter, which acts as an incompetent valve during urination. </li></ul>
  28. 38. <ul><li>The ratio of the submucosal tunnel length to the ureteral diameter is the primary factor determining the effectiveness of the normal valve mechanism. </li></ul><ul><li>It is normally 5:1, and in those with reflux it is 1.4:1. </li></ul><ul><li>The intramural length increases from 0.5 cm at birth to 1.3 cm by 12 years of age. </li></ul><ul><li>Duplication of the collecting system and ureteroceles should also be considered. </li></ul>
  29. 41. SOME CLINICAL FACTS ABOUT VUR: <ul><li>It is genetic. </li></ul><ul><li>Occurs in about 30% of first-degree relatives. </li></ul><ul><li>1/3 of children with a urinary tract infection has reflux on VCUG. </li></ul><ul><li>Primary reflux tends to resolve over time as intravesical segment elongates with growth. </li></ul>
  31. 43. PROGNOSIS: <ul><li>Resolves spontaneously before adolescence in: </li></ul><ul><ul><li>90% of Gr. 1 reflux </li></ul></ul><ul><ul><li>80% of Gr. 2 </li></ul></ul><ul><ul><li>50% of Gr. 3 </li></ul></ul><ul><ul><li>10% of Gr. 4 </li></ul></ul><ul><ul><li>0 in Grade 5 reflux </li></ul></ul><ul><li>Kidney is most susceptible to scarring in the first year of life and at the time of first upper tract infection. </li></ul><ul><li>Scars less frequently develop after the age of 5. </li></ul><ul><li>VUR and scarring lead to hypertension, progressive renal insufficiency and failure. </li></ul>
  32. 44. TREATMENT: <ul><li>Observation </li></ul><ul><li>Medical treatment of infections </li></ul><ul><li>Surgical treatment </li></ul><ul><ul><li>significant hydroureteronephrosis </li></ul></ul><ul><ul><li>indicated if impossible to keep urine sterile and reflux persists </li></ul></ul><ul><ul><li>acute pyelonephritis occurs </li></ul></ul><ul><ul><li>evidence of increasing renal damage </li></ul></ul>
  33. 45. ON PRESENTATION, HOW DO WE MANAGE? <ul><li>Antenatal diagnosis of HN </li></ul><ul><li>Enlarged palpable kidneys on PE </li></ul><ul><li>Incidental finding on UTS done for other anomalies. </li></ul>
  34. 46. <ul><li>Management would depend on the clinical condition of the patient and the suspected nature of the lesion. </li></ul><ul><li>More common to have a unilateral HN that is not associated with systemic or pulmonary complications. </li></ul><ul><ul><li>Postnatal UTS confirmation at about 1 month of life, depending on severity. </li></ul></ul><ul><li>Bilateral HN </li></ul><ul><ul><li>urgent work-up especially when accompanied by oligohydramnios and pulmonary disease </li></ul></ul><ul><ul><li>if male infant, postnatal VCUG and UTS </li></ul></ul>
  35. 47. <ul><li>Prophylactic antibiotics (Amoxicillin 20mg/kg PO daily) before VCUG is performed, as hydronephrosis may be due to reflux. </li></ul><ul><li>DMSA scan to evaluate renal function. </li></ul><ul><li>Definitely: </li></ul><ul><ul><li>Check presence and regularity of voiding. </li></ul></ul><ul><ul><li>Mild HN: UA, BMP </li></ul></ul><ul><ul><li>Moderate: UA, BMP, VCUG </li></ul></ul><ul><ul><li>Refer to specialist </li></ul></ul>
  36. 48. REFERENCES: <ul><li>Tanagho and McAninch. Smith’s General Urology.16th ed: 2004, McGraw-Hill Companies, USA. </li></ul><ul><li>Zitelli and Davis. Atlas of Pediatric Physical Diagnosis. 4th ed:2002, Mosby, Inc., USA. </li></ul><ul><li>Resnick and Novick. Urology Secrets. 3rd ed:2003, Hanley and Belfus, Inc., USA. </li></ul><ul><li>Edmondson, J.D. Antenatal Hydronephrosis . Mar 2004, Emedicine article. </li></ul><ul><li>Wiener, J.S. Ureteropelvic Junction Obstruction, Congenital . Aug 2004, Emedicine article. </li></ul><ul><li>Maniam, P. Hydronephrosis and Hydroureter . Aug 2004, Emedicine article. </li></ul><ul><li>Div of Urology, Children’s Hosp, Boston, MA. Neonatal Hydronephrosis . Digital Urology Journal. Internet download. </li></ul>
  37. 49. REFERENCES: <ul><li>McCarthy, K. Vesicoureteral Reflux . Mar 2004, Emedicine article. </li></ul><ul><li>Behrman, et al. Nelson Textbook of Pediatrics. 17th ed: Saunders Co., USA. </li></ul><ul><li>Lloyd-Davies, et al. Color Atlas of Urology. 2nd ed:Mosby-Year Book Europe Limited, London, England. </li></ul><ul><li>Gillenwater, et al. Adult and Pediatric Urology. 4th ed, Vol. I: 2002, Lippincott Williams and Wilkins, USA. </li></ul><ul><li>Cloherty, et al. Manual of Neonatal Care. 5th ed: 2004, Lippincott Williams and Wilkins, USA. </li></ul><ul><li>Gonzales and Bauer. Pediatric Urology Practice. 1999: Lippincott Williams and Wilkins, USA. </li></ul>