Hydronephrosis is the dilation of the renal pelvis and calyces due to urine obstruction, leading to kidney damage. It can occur from various causes, including congenital anomalies, urinary calculi, and tumors, with the effects varying from acute to chronic conditions. Diagnosis involves imaging studies, and treatment may be non-operative or require surgical intervention depending on the severity and symptoms.

1. Dr Vijay Kumar
Associate Professor
HYDRONEPHROSIS
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2. Hydronephrosis.
• Hydronephrosis - dilation of
the renal pelvis and calyces
with urine, associated with
progressive atrophy of the
kidney due to obstruction to
the outflow of urine
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4. Types of Obstruction
• SUDDEN / INSIDIOUS
• PARTIAL / COMPLETE
• UNILATERAL / BILATERAL
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5. Epidemiology
• Autopsy 3.1%
• Differences based on sex did not become
apparent until age 20 years.
• At age 20-60 years, hydronephrosis was
more common in women, due to pregnancy
and gynecologic malignancy.
• In men, prostatic diseases - cause of the rise
in prevalence > 60 years.
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7. Types of Lesions
Causative lesions may be:-
• Intrinsic to the urinary tract or
• Extrinsic lesions - compress ureter
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8. Obstructive lesions of the urinary tract
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9. Etiology
• 1. Congenital anomalies
• 2. Urinary calculi
• 3. Benign prostatic hypertrophy
• 4. Tumors
• 5. Inflammation
• 6. Sloughed papillae or blood clots
• 7. Pregnancy
• 8. Uterine prolapse and cystocele
• 9. Functional disorders
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10. Etiology
• Congenital
– urethral valves or stricture
– stenosis at the UVJ or PUJ → majority of cases
in children.
• Calculi are most common in young adults
• Prostatic hypertrophy or carcinoma
retroperitoneal or pelvic neoplasms, and
calculi → in older patients.
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11. Physiological
• Hydronephrosis or hydroureter is normal pregnancy
• More prominent on the right
• These changes can be visualized on USG in 2nd
trimester
• Resolve 6-12 weeks postpartum
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14. Acute Vs. Chronic
• Acute hydronephrosis , when corrected,
allows full recovery of renal function.
• Chronic hydronephrosis - loss of function is
irreversible
• If acute unilateral obstruction is corrected
within 2 weeks, full recovery of renal
function is possible
• After 6 weeks of obstruction, function is
irreversibly lost
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15. When the obstruction is SUDDEN & COMPLETE
GFR IS REDUCED
• It leads to
• MILD DILATION OF PELVIS and CALYCES
and sometimes to
• ATROPHY OF THE RENAL PARENCHYMA
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16. When the obstruction is
• SUBTOTAL or INTERMITTENT
→GFR IS NOT SUPPRESSED and
• PROGRESSIVE DILATION
ENSUES
• Kidney may be slightly to massively
ENLARGED, depending on the
degree and the duration 16

17. • In far-advanced cases the kidney may
become transformed into
• A THIN-WALLED CYSTIC
STRUCTURE with a diameter 15 - 20 cm
• with striking PARENCHYMAL
ATROPHY
• TOTAL OBLITERATION OF THE
PYRAMIDS, and
• THINNING OF THE CORTEX
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18. Complications
Urinary stasis may result in
• Infection
• Renal scarring
• Calculus formation
• Sepsis
• Renal failure
• Hypertension
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19. Clinical Features
I. Acute obstruction –
• PAIN d/t distention of the renal
capsule
• The site of obstruction -
– Upper ureteral or renal pelvic lesions
lead to flank pain or tenderness
– Lower ureteral obstruction causes pain
that may radiate to the ipsilateral
testicle or labia.
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20. Clinical Features
• II Unilateral HDN remain SILENT FOR
LONG PERIODS, since the opposite kidney
can maintain adequate renal function.
• Sometimes detected in routine USG or IVP
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21. Clinical Features
III. In B/L partial obstruction the earliest
manifestation is inability to concentrate
the urine, reflected by
1. POLYURIA
2. NOCTURIA.
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22. Clinical Features
Other symptoms
• Anuria
• Hematuria
• Fever
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23. Clinical Features:Physical Exam
• Kidney lump
• With B/L hydronephrosis, lower limb
edema may occur.
• Renal angle tenderness +
• Distended bladder
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24. Diagnostic Studies
• Laboratory Tests
• Imaging
– X-ray + Contrast studies.
– USG
– CT
– MRI
– Nuclear Scan
• Other Tests
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25. Laboratory Studies
• Urinalysis-
– Pyuria -means- infection.
– Microscopic hematuria → presence of a stone
or tumor.
• Leukocytosis -acute infection.
• Serum Creatinine levels
• Hypercalcemia can be a life-threatening
condition.
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26. Imaging studies
• Renal ultrasonography is the test of choice
• Intravenous Urography
• CT Indications :
– Ultrasonography results are equivocal
– The kidneys cannot be well visualized
– The cause of the obstruction cannot be identified.
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27. DTPA renal scan - kidney function and blood flow
Technetium-99m (Tc-99m) labeled DTPA(Diethylenetriaminepentaacetic
acid) is injected into the bloodstream, and its clearance from the kidneys
→ renal function. 27
D
T
P
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28. Imaging in children
• Antenatal hydronephrosis -visible in USG
usually occurs in the II trimester
• Postnatal USG
• A voiding cystourethrography (VCUG) -
detect VUR and, in boys, evaluate the
posterior urethra.
• Magnetic resonance urography (MRU)
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29. Differential Diagnosis
Other problems to consider in the differential
diagnosis include the following:
• Peripelvic cyst
• Congenital megacalyces
• Calyceal diverticula
• Capacious extrarenal pelvis
• Pyelonephritis
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30. Non Operative Therapy
• Pain control
• Treatment or prevention of infection
• Oral alkalinization therapy for uric acid
stones and
• Steroid therapy for retroperitoneal fibrosis.
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31. Minimally invasive Therapy
• Extracorporeal shockwave lithotripsy
• Urethral Catheterisation.
• SPC
• Ureteral catheterisation +- stent
• Nephrostomy
• Post. Urethral Valve fulguration.
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32. Operative Therapy:Indications
• Any signs of infection Fever, leukocytosis
• The potential for loss of renal function also
adds to the urgency (eg, hydronephrosis or
hydroureter bilaterally or in a solitary
kidney)
• Refractory pain in a patient with an
obstructing ureteral calculus necessitates
intervention
• Intractable nausea and vomiting.
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