2. Hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Obstructive uropathy: Functional or anatomic obstruction of
urinary flow at any level of urinary tract
Obstructive nephropathy: Obstruction causes functional or
anatomic renal damage
• Thus, the terms hydronephrosis & obstruction should not be
used interchangeably
3. Hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Obstructive uropathy: Functional or anatomic obstruction of
urinary flow at any level of urinary tract
Obstructive nephropathy: Obstruction causes functional or
anatomic renal damage
• Thus, the terms hydronephrosis & obstruction should not be
used interchangeably
4. Hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Obstructive uropathy: Functional or anatomic obstruction of
urinary flow at any level of urinary tract
Obstructive nephropathy: Obstruction causes functional or
anatomic renal damage
• Thus, the terms hydronephrosis & obstruction should not be
used interchangeably
9. Hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Obstructive uropathy: Functional or anatomic obstruction of
urinary flow at any level of urinary tract
Obstructive nephropathy: Obstruction causes functional or
anatomic renal damage
• Thus, the terms hydronephrosis & obstruction should not be
used interchangeably
10. Hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Obstructive uropathy: Functional or anatomic obstruction of
urinary flow at any level of urinary tract
Obstructive nephropathy: Obstruction causes functional or
anatomic renal damage
• Thus, the terms hydronephrosis & obstruction should not be
used interchangeably
11. Etiology
Lusaya DG, et al. Medscape. 2015.
• Etiology & presentation of hydronephrosis and/or
hydroureter in adults differ from that in neonates & children
Anatomic abnormalities (including urethral valves or stricture
& stenosis at ureterovesical or ureteropelvic junction)
account for majority of cases in children
• Calculi are most common in young adults
• Prostatic hypertrophy or carcinoma, retroperitoneal or pelvic
neoplasms & calculi are primary causes in older patients
12. Hydronephrosis in pregnancy
Lusaya DG, et al. Medscape. 2015.
• Hydronephrosis or hydroureter: Normal finding in pregnant women
• Renal pelvises & caliceal systems may be dilated as a result of
progesterone effects & mechanical compression of ureters at pelvic
brim
• Dilatation of ureters & renal pelvis is more prominent on right side
than left side and is seen in up to 80% of pregnant women
• These changes can be visualized on ultrasound examination by 2nd
trimester & they may not resolve until 6-12 weeks post partum
13. Pathophysiology
• However, extra-renal components can dilate to point of
tortuosity
Lusaya DG, et al. Medscape. 2015.
• Increased ureteral pressure also results in pyelovenous &
pyelolymphatic backflow
Gross changes within urinary tract similarly depend on
duration, degree & level of obstruction
• Within intrarenal collecting system, degree of dilation is
limited by surrounding renal parenchyma
14. Pathophysiology
• However, extra-renal components can dilate to point of
tortuosity
Lusaya DG, et al. Medscape. 2015.
• Increased ureteral pressure also results in pyelovenous &
pyelolymphatic backflow
Gross changes within urinary tract similarly depend on
duration, degree & level of obstruction
• Within intrarenal collecting system, degree of dilation is
limited by surrounding renal parenchyma
15. Pathophysiology
• However, extra-renal components can dilate to point of
tortuosity
Lusaya DG, et al. Medscape. 2015.
• Increased ureteral pressure also results in pyelovenous &
pyelolymphatic backflow
Gross changes within urinary tract similarly depend on
duration, degree & level of obstruction
• Within intrarenal collecting system, degree of dilation is
limited by surrounding renal parenchyma
16. Acute and chronic hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Microscopic changes consist of dilation of tubular lumen &
flattening of tubular epithelium
• Fibrotic changes & increased collagen deposition are
observed in peritubular interstitium
17. Acute and chronic hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Microscopic changes consist of dilation of tubular lumen &
flattening of tubular epithelium
• Fibrotic changes & increased collagen deposition are
observed in peritubular interstitium
18. Acute and chronic hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• Microscopic changes consist of dilation of tubular lumen &
flattening of tubular epithelium
• Fibrotic changes & increased collagen deposition are
observed in peritubular interstitium
19. Causes
Lusaya DG, et al. Medscape. 2015.
• A multitude of causes exist for hydronephrosis & hydroureter
• Classification can be made according to level within urinary
tract & whether etiology is intrinsic, extrinsic or functional
20. Intrinsic ureter level
Lusaya DG, et al. Medscape. 2015.
• Causes can be as follows:
Benign fibroepithelialpolyps
:° Ureteral tumor
Fungus ball
Ureteral calculus
‹ Ureterocele
-‹ Endometriosis
Tuberculosis
‹ Retrocaval ureter
21. Intrinsic ureter level
Lusaya DG, et al. Medscape. 2015.
• Causes can be as follows:
Benign fibroepithelialpolyps
:° Ureteral tumor
Fungus ball
Ureteral calculus
‹ Ureterocele
-‹ Endometriosis
Tuberculosis
‹ Retrocaval ureter
22. Functional ureter level
Lusaya DG, et al. Medscape. 2015.
• Causes can be as follows:
Gram-negative infection
y Neurogenic bladder
23. Extrinsic ureter level
Lusaya DG, et al. Medscape. 2015.
• Causes can be as follows:
i Pregnancy
:r. latrogenic ureteral ligation
: Ovarian cysts
i‹. Diverticulitis
: Tuboovarian abscess
1 Retroperitoneal hemorrhage
/ Lymphocele
‹v. Pelvic lipomatosis
‹‘‹. Radiation therapy
›‹: Urinoma
24. Extrinsic ureter level
‹v.
‹‘‹.
›‹:
Pelvic lipomatosis
Radiation therapy
Urinoma
Lusaya DG, et al. Medscape. 2015.
• Causes can be as follows:
i Pregnancy
:r. latrogenic ureteral ligation
: Ovarian cysts
i‹. Diverticulitis
: Tuboovarian abscess
1 Retroperitoneal hemorrhage
/ Lymphocele
25. • Intrinsic bladder level causes can be as follows:
Bladder carcinoma
Bladder calculi
Bladder neck contracture
Cystocele
Primary bladder neck hypertrophy
Bladder diverticula
• Functional bladder level causes can be as follows:
Neurogenic bladder
Vesicoureteral reflux
• Extrinsic bladder level causes can include pelvic lipomatosis
Lusaya DG, et al. Medscape. 2015.
26. Urethra
Phimosis
Lusaya DG, et al. Medscape. 2015.
° Intrinsic urethra level causes can be as follows:
Urethral stricture
Urethral valves
Urethral diverticula
Urethral atresia
Labial fusion
Hypospadias & epispadias
• Extrinsic urethra level causes can be as follows:
Benign pro5tatic hyperplasia
Prostate cancer
Urethral & penile cancer
27. Urinary Tract Obstruction
Obstructions in urinary tract:
Reduce urinary flow: Impair
renal function
Frequent effect of partial or
complete obstruction is
dilation of renal pelvic
(hydronephrosis)
Rena ••
Obstructions of urinary tract
are painful & need immediate
treatment
Obs
'*c
’Rd
Ureter
Hydronephrosis
28. Calculi
{Et!eticopen nq
Cancer of
-Ovary
-CerviX
-Uterus
Prostatic hypertrophy
or cancer u ethfa
-enaI pelvis
ure'er
Congenital pelviureteric
junction obstruction
adderw
as
Retroperitoneal fibrosis,
tumours, haemorrhage
Functional: vesicoureteric
reflux
eurogenic bladder
QfoSfate giano
[males a Iy]
Bladder cancer
31. Clinical features
• Bilateral symmetrical hydronephrosisusually suggests a cause
related to bladder, such as retention, prostatic blockage, or severe
bladder prolapse
Lusaya DG, et al. Medscape. 2015.
A history of hematuria may herald a stone or malignancy anywhere
in urinary tract
• A history of fever or diabetes adds urgency to evaluation &
treatment
• A history of a solitary kidney is an emergent situation
• Hydronephrosis may develop silently, without symptoms, as result
of advanced pelvic malignancy or severe urinary retention from
bladder outlet obstruction
32. Clinical features
• Bilateral symmetrical hydronephrosisusually suggests a cause
related to bladder, such as retention, prostatic blockage, or severe
bladder prolapse
Lusaya DG, et al. Medscape. 2015.
A history of hematuria may herald a stone or malignancy anywhere
in urinary tract
• A history of fever or diabetes adds urgency to evaluation &
treatment
• A history of a solitary kidney is an emergent situation
• Hydronephrosis may develop silently, without symptoms, as result
of advanced pelvic malignancy or severe urinary retention from
bladder outlet obstruction
33. Clinical features
• Bilateral symmetrical hydronephrosisusually suggests a cause
related to bladder, such as retention, prostatic blockage, or severe
bladder prolapse
Lusaya DG, et al. Medscape. 2015.
A history of hematuria may herald a stone or malignancy anywhere
in urinary tract
• A history of fever or diabetes adds urgency to evaluation &
treatment
• A history of a solitary kidney is an emergent situation
• Hydronephrosis may develop silently, without symptoms, as result
of advanced pelvic malignancy or severe urinary retention from
bladder outlet obstruction
34. Clinical features
• Bilateral symmetrical hydronephrosisusually suggests a cause
related to bladder, such as retention, prostatic blockage, or severe
bladder prolapse
Lusaya DG, et al. Medscape. 2015.
A history of hematuria may herald a stone or malignancy anywhere
in urinary tract
• A history of fever or diabetes adds urgency to evaluation &
treatment
• A history of a solitary kidney is an emergent situation
• Hydronephrosis may develop silently, without symptoms, as result
of advanced pelvic malignancy or severe urinary retention from
bladder outlet obstruction
35. Clinical features
• Bilateral symmetrical hydronephrosisusually suggests a cause
related to bladder, such as retention, prostatic blockage, or severe
bladder prolapse
Lusaya DG, et al. Medscape. 2015.
A history of hematuria may herald a stone or malignancy anywhere
in urinary tract
• A history of fever or diabetes adds urgency to evaluation &
treatment
• A history of a solitary kidney is an emergent situation
• Hydronephrosis may develop silently, without symptoms, as result
of advanced pelvic malignancy or severe urinary retention from
bladder outlet obstruction
36. Pediatric hydronephrosis and hydroureter
Lusaya DG, et al. Medscape. 2015.
• Fetal hydronephrosis is readily diagnosed finding on antenatal
ultrasound examination & can be detected as early as 12th -
14th week of gestation
• Although renal pelvic dilatation is transient, physiologic state
in most cases, urinary tract obstruction & vesicoureteral
reflux (VUR) are also causal
• Most cases of antenatal hydronephrosis are not clinically
significant & can lead to unnecessary testing of newborn
baby and anxiety for patients and healthcare providers
37. Physical
Lusaya DG, et al. Medscape. 2015.
• With severe hydronephrosis, kidney may be palpable
° With bilateral hydronephrosis, lower extremity edema may
occur
• Costovertebral angle tenderness on affected side is common
• A palpably distended bladder adds evidence of lower urinary
tract obstruction
• A digital rectal examination should be performed to assess
sphincter tone & to look for hypertrophy, nodules, or
induration of prostate
38. In children
Lusaya DG, et al. Medscape. 2015.
• Presence of outer ear abnormalities is associated with
increased risk of congenital anomalies of kidney & urinary
tract (CAKUT)
• A single umbilical artery is associated with increased risk of
CAKUT, particularly VUR
39. In children
Lusaya DG, et al. Medscape. 2015.
• Presence of outer ear abnormalities is associated with
increased risk of congenital anomalies of kidney & urinary
tract (CAKUT)
• A single umbilical artery is associated with increased risk of
CAKUT, particularly VUR
41. Medical care
Lusaya DG, et al. Medscape. 2015.
• Management approach to infants with antenatal
hydronephrosis is based on confirmation of persistent
postnatal hydronephrosis & following 2 predictive factors:
Bilateral involvement
• Severe hydronephrosis: Fetuses with renal pelvic diameter <
15 mm during 3rd trimester are at greatest risk for significant
renal disease
42. Medical care
Lusaya DG, et al. Medscape. 2015.
• Management approach to infants with antenatal
hydronephrosis is based on confirmation of persistent
postnatal hydronephrosis & following 2 predictive factors:
Bilateral involvement
• Severe hydronephrosis: Fetuses with renal pelvic diameter <
15 mm during 3rd trimester are at greatest risk for significant
renal disease
43. Bilateral hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• If postnatal ultrasonography demonstrates persistent
hydronephrosis, voiding cystourethrography (VCUG) should
be performed
• In male infants: Posterior urethra should be fully evaluated to
detect possible PUVs
• Infants with mild or moderate hydronephrosis can be
evaluated after 7 days of life
44. Bilateral hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• If postnatal ultrasonography demonstrates persistent
hydronephrosis, voiding cystourethrography (VCUG) should
be performed
• In male infants: Posterior urethra should be fully evaluated to
detect possible PUVs
• Infants with mild or moderate hydronephrosis can be
evaluated after 7 days of life
45. Severe unilateral hydronephrosis
Lusaya DG, et al. Medscape. 2015.
• In newborns with severe antenatal unilateral hydronephrosis
(renal pelvic diameter >15 mm in 3rd trimester),
ultrasonography should be performed after infant returns to
birth weight (after age 48 h & within 1st 2 wk of life)
46. Moderate & mild unilateral
hydronephrosis
• Of 18 patients with persistent hydronephrosis,14 had
ureteropelvic junction (UPJ) obstruction & 4 had
vesicoureteral reflux (VUR)
Lusaya DG, et al. Medscape. 2015.
• Moderate hydronephrosis resolves by age 18 months in most
cases. This was illustrated by prospective study of 282 infants
(age 2 mo) with renal pelvic diameters between 10 & 15 mm,
which resolved in 94% of patients by age 12-14 months
(resolution was defined as renal pelvic diameter ñ5 mm on 2
consecutive ultrasounds)
47. Moderate & mild unilateral
hydronephrosis
• Of 18 patients with persistent hydronephrosis,14 had
ureteropelvic junction (UPJ) obstruction & 4 had
vesicoureteral reflux (VUR)
Lusaya DG, et al. Medscape. 2015.
• Moderate hydronephrosis resolves by age 18 months in most
cases. This was illustrated by prospective study of 282 infants
(age 2 mo) with renal pelvic diameters between 10 & 15 mm,
which resolved in 94% of patients by age 12-14 months
(resolution was defined as renal pelvic diameter ñ5 mm on 2
consecutive ultrasounds)
49. Anderson-Hynes pyeloplasty
Anderson—Hynes dismembered pyeloplasty. a |Marking stitches are
placed on the renal pelvis superior to the obstruction and the lateral aspect of the
proximal ureter below the level of the obstruction. b |The ureteropelvic junction
tissue is then excised and an anastomosis is created with fine interrupted or
running absorption sutures.c | The sutures are placed in a watertight manner over
an internal ureteral stent, which remains in site.
Khan F, et al. Nature Reviews Urology 11, 629-638 (2014).
50. Scant J Or‹M Wophrol 2l:2D3—217,
1flH7
H j v i net I_Jricle r R j e r g Pmtil sen, Trtie1s Of finch J a r g e n s e n , F i n u TaapeYieïj -J e n t e n
a n d Jeris 4?hri stian D j u r h uus
Abstract. 35 patients, age W9 years, mean 27, with pyelo-
uretcric junction obstruction and hydronephrosis on I.V. R
were operated by Anderson-Hynes pyeltiplasty. Prior to
operation all patients were further investigated by renal
scintigraphy. The postoperative follow-up consisted of a sec-
ond l.V. P. after 12 months and repeated scintigraphies once
or twice yearly. Mean follow-up time was 28 months. Thirty-
three % of ihe patients with a decreased 2 min uptake frac-
tion preoperativeiy had a significant increase in renal func-
tion after surgery. Th1s increase wRs seen within the first 2
munths. The rate of increase was greatest in patients below
30 years. Older patients only showed stabilized function.
None of the patients had significant decrease in renal func-
tion. There was no corr2la1ion between thc change in renal
function and change in the I.V.P. It is concluded that an ac-
tive surgical attitude in hydronephrosis is justified. Further-
more, follow-up after reconstruction could be limited to a
rcnography 6 and 12 months postoperatively in otherwise
asymptomatic cases with stable or improved uptake frac-
51. Culp-DeWeerd spiralflap
Khan F, et al. Nature Reviews Urology 11, 629-638 (2014).
a | A spiral incision is made in enlarged renal pelvis & extended an
equal distance into ureter. b | Tissue flap is turned down &
stitched into adjacent ureter. c | Flap is closed with fine
interrupted or running absorption sutures
52. Foley Y-plasty
Khan F, et al. Nature Reviews Urology 11, 629-638 (2014).
I Foley Y-V plasty. a |The ureter is pulled with a stitch while a Y-shaped
incision is made in the renal pelvis and ureter. b| A V-shaped flap is opened in
the ureteropelvic junction tissue. c |The V-shaped flap is sutured to the apex
of the ureteral incision with fine interrupted or running absorption sutures.
55. Society of Fetal Urology grading system for
antenatally detected hydronephrosis
Central renal
complex = Pelvis
Grade
Renal
parenchynial
thickness
0
I
II
Intact
Mild splitting = dilatarion
Moderate splitting, but complex
confined within renal border
Marked splitting, pelvis dilated
outside renal border, and coffees
dilated
Further pelviealyceal dilatation
Normal
Normal
Normal
III Normal
IV Thin
56. lassification Renal elvic anteroosterior diameter, APD
econd trimester hird trimester
N0derate 10-15 m
m
$evere >10 M
M | ›15 M
M
Sinha A, et al. Indian Pediatr 2013;50: 215-231.
Classification of antenatal hydronephrosis, based on
renal pelvic anteroposterior diameter
57. Renal Abnormal(ties
Oligohydramnios dilated or thick-walled bladder
Calyceal dilatation Ureteral dilatation
Perinephric urinoma |KeyhoIe sign
Loss of renal arench ma, as su ested b
ortical thinnin
” oor corticome erentiation
”ncrease rena ec enici
”ena
temfc A ’ities
Major systemic structural anomaly, e.g., cardiovascular, neurological, gastrointestinal,
keletal s stem
Increased nuchal translucency choqenic focus in the heart”
Absent nasal bone |Shortened long bones (humerus, femur)
Ec enic owe exus c st
Hydronephrosis entriculome
Additional parameters evaluated on antenatal
ultrasonography
“ Limited significance of echogenic cardiac focus in Indian patients
Sinha A, et al. Indian Pediatr 2013;50: 215-231.
58. Causes of antenatal hydronephrosis (most of
which can cause bilateral hydronephrosis)
Renal
Physiological/transient hydronephrosis
PUJ obstruction
Vesico-ureteric reflux
Posterior urethral valves
Megaureter (obstructed or non-obstructed)
Multicystic dysplastic kidney
Ureterocele
Ectopic ureter
Prune belly
Urethral atresia
Renal cysts
Urachal cyst
NOn-renal
Ovarian cyst
Hydrocolpos
Sacrococcygeal teratOfRa
Enteric duplication
Duodenal atresia
Meningocele
59. Sinha A, et al. Indian Pediatr 2013;50: 215-231.
60. Sallami Sataa*’,Cherif Kerim*,Ben Rhouma Sami*,Dagudagui Nizar*,Ilkid Rochdi*,Kchir
Nidhameddine',Horchani Ali'
Giant hydronephrosis in adults:What isie best approach? Reoospective
analysis of 24cases
61. • Definition of GH: Adult renal pelvis containing 1 litre of urine of
1.6% of body weight
• Crooks et ad. has given radiographic criteria: 1) Kidney occupies
hemi-abdomen 2) Meets of crosses midline 3 about 5
vertebral bodies in length
• Seen more often in sales than in females (2.4:1)
• > 500 cases of GHhave been reported in literature
• GH usually presents: Asymptomatic enlargement of abdomen
noticed by patient of incidentally by his physician
62. Giant hydronephrosis in adults:What is ie
analysis of 24cases
best approach? Reoospective
Flank pain / Abdominal lump
Non contrast CT Scan
RcrtBl Parenchyma thickness
IVU/CT Scan
Scintigraphy +/-Pyelography
Funciionnl *20°/»
Functional < 20°/«
63. Sallami Sataa*’,Cherif Kerim*,Ben Rhouma Sami*,Dagudagui Nizar*,Ilkid Rochdi*,Kchir
Nidhameddine',Horchani Ali'
Giant hydronephrosis in adults:What isle best approach? Reoospective
analysis of 24cases
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