Hydronephrosis is defined as the dilatation of renal pelvis and calyces, which can occur due to obstruction or be present without it. Causes vary from extramural, intramural, to intraluminal factors that can lead to unilateral or bilateral hydronephrosis, with clinical features depending on the severity and presentation. Treatment focuses on relieving urine buildup, preventing kidney damage, and addressing the underlying cause, utilizing methods such as catheterization, ureter stenting, or surgical interventions.

1. HYDRONEPHROSIS
DR RANJIT SINGH RATHORE
Asso. Proff (Urology)
Dept of General surgery, ASCOMS

2. DEFINITION
• Dilatation of renal pelvis & calyces with accompanying destruction of the kidney
parenchyma
• It may be associated with obstruction but may be present in the
absence of obstruction
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3. HYDRONEPHROSIS
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4. 4
ETIOLOGY
SECONDARY
UNILATERA
L
BILATERAL
PRIMARY IDIOPATHIC

5. UNILATERAL
CAUSES
EXTRAMURAL
INTRAMURAL
INTRALUMINAL

6. 6

7. UNILATERAL HYDRONEPHROSIS- EXTRAMURAL
• Pressure on the ureter by loaded sigmoid colon, gravid
uterus, uterine & ovarian tumors
• Involvement of the ureter by malignant neoplasm outside
it e.g. carcinoma of the cervix, uterus, colon, rectum,
prostate
• Aberrant renal vessels
• Idiopathic retroperitoneal fibrosis
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8. UNILATERAL HYDRONEPHROSIS- INTRAMURAL
•Intramural:
• Congenital stenosis or achalasia
of the PUJ
• Ureterocele
• Stricture
• Neoplasm of ureter
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9. UNILATERAL HYDRONEPHROSIS- INTRA LUMINAL
•Intraluminal:
• Calculus
• Congenital folds at the upper
end of the ureter
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10. CAUSES OF BILATERAL HYDRONEPHROSIS
• Due to pathologies in the urethra or the urinary bladder
• Causes in the urethra:
• Meatal stenosis
• Posterior urethral valve
• BPH & carcinoma of prostate
• Stricture
• Carcinoma of cervix & uterus
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11. CAUSES OF BILATERAL HYDRONEPHROSIS
•Causes in the bladder:
• Calculus
• Neoplasms
• Sphincter dysfunction
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13. 14

14. CLINICAL FEATURES
• May depend on unilateral, intermittent or
bilateral hydronephrosis
• Dull ache & sense of weight on the affected side of
the loin
• Causes of the hydronephrosis
• Dietl’s crisis
• Features of the causes
• Bilateral renal swelling
15

15. EVALUATION
Depending upon the presentation and
whether there is acute onset of symptoms,
•Physical examination - tenderness in the flank or
where the kidneys are located.
•The bladder - distended when the abdomen is
examined.
•PR for males shows the size of the prostate. 50

16. •Urine analysis to look for blood, infection or
abnormal cells
•Complete blood count (CBC) may reveal anemia
or potential infection
•Electrolyte analysis may be helpful in chronic
hydronephrosis since the kidneys are responsible
for maintaining and balancing their concentrations
in the blood stream.
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17. X RAY KUB
KUB X-rays (an X-ray that shows the kidney,
ureter, and bladder) are used to classify a
kidney stone as radiodense or
radiolucent.
KUB X-rays are used to determine if the
stone is able to migrate down the ureter
into the bladder.
52

19. NORMAL KIDNEY HYDRONEPHROSIS
20

20. IVP
• IVP : Dilatation of renal
pelvis decreasing
concavity and then
flattening of minor
calyces with dilatation
of major calyces a
portion of pelvis
becomes more
dependant part below
the level of PVJ 53

21. NORMAL INTRAVENOUS PYELOGRAM (IVP) 19

23. SPECIAL
INVESTIGATIONS
•Excretory urography
•Retrograde urography
•Ultrasound
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24. Excretory Urogram

25. Retrograde Pyelogram (RP)
• Retrograde pyelogram is used to determine
whether stone or other thing that is obstructing the
urinary pathway.
• This is used in Some people with contra indictions
for IVP in which dye is introduced into the veins.

26. •CT scan of the abdomen can be done to
evaluate the kidney anatomy and it will help
in making the diagnosis of hydronephrosis.
•It also may allow look for the underlying cause
including kidney stones or structures that are
compressing the urinary collecting system.
CT scan

27. For patients with ureteral
strictures or stones that are
difficult to remove, stent may
be placed into the ureter that
bypasses the obstruction and
allows urine to flow from the
kidney.
63

28. PRINCIPLES OF TREATMENT
In adults, the aims of treatment are to:
•Remove the build-up of urine and relieve
tthe pressure on kidneys.
•Prevent permanent kidney damage.
•Treat the underlying cause

29. •Most people with hydronephrosis should have
catheterisation to drain the urine from their
kidneys.
•Depending on the underlying cause, medication
or surgery may be needed afterwards to correct
the problem.
•If the condition is severe or causing problems such
as a urinary tract infection (UTI), it may be treated
soon after it is diagnosed.

30. TREATMENT GOAL
•
•
•
•
The goal of treatment for hydronephrosis is to restart the
free flow of urine from the kidney and decrease the
swelling and pressure that builds up and decreases
kidney function.
The initial care for the patient is aimed at minimizing
pain and preventing urinary tract infections.
The timing of the procedure depends upon
the :underlying cause of hydronephrosis and
hydroureter and the associated medical conditions
that may be present. 60

31. For patients with urinary retention and an
enlarged bladder as a cause of hydronephrosis,
bladder catheterization may be all that is
needed for initial treatment.
When a stent cannot be placed, an alternative
is inserting a percutaneous nephrostomy
tube. A urologist or interventional radiologist
uses fluoroscopy to insert a tube through the
flank directly into the kidney to allow urine to
drain.
61

32. Per cutaneous Nephrostomy :

33. Shock wave lithotripsy(SWL )
Shock wave lithotripsy(SWL or
extracorporeal shock wave
lithotripsy) is the most common
treatment for kidney stones.
Shock waves from outside the
body are targeted at a kidney
stone causing the stone to
fragment into tiny pieces that
are able to be passed out of the
urinary tract in the urine. 62

34. For patients with ureteral
strictures or stones that are
difficult to remove, stent may
be placed into the ureter that
bypasses the obstruction and
allows urine to flow from the
kidney.
63

35. Using a ureteroscope inserted through the urethra
into the bladder, can visualize where the ureter
enters and can thread the stent through the ureter
into the kidney pelvis bypassing any obstruction.

36. Treating hydronephrosis in
babies
Most babies diagnosed with hydronephrosis before they're born (antenatal
hydronephrosis) won't need any treatment because the condition will improve
before they're born or within a few months of their birth.
Investgiations are done for babies like:
• An ultrasound scan
• Micturating cystourethrogram (MCUG) – where a thin tube is used
to pass a special type of liquid that shows up clearly on X-rays into
thebaby's bladder while a series of X-rays are taken.

37. • Dimercaptosuccinic acid (DMSA) scan or MAG-3 scan –
where they are injected with a substance that shows up on a special device
called a gamma camera; the camera is then used to take pictures of child's
kidneys
•In most children, hydronephrosis will get better as they get older.
•If hydronephrosis doesn't get better by itself, child may need to keep taking
antibiotics.
•Occasionally, surgery may be recommended to treat the underlying cause
of the condition

38. INDICATIONS OF OPERATIONS :
•Increasing renal pain increasing hydronephrosis
•When hydronephrosis is complicated by
infection/parenchymal damage.
PROCEDURES :
Nephrectomy
•Plastic operations
•Endoscopic pyelolysis / endoscopic pyelotomy
•Endoscopic ballon dilatation

39. Principles of pyeloplasty
•To reduce the size of the renal pelvis
•Excision of the PUJ
•The ureter is attached to the most dependent part of
the pelvis

40. 67
Extraperitoneal flank approach,
bed of the 12th rib

41. TREATMENT
•Secondary hydronephrosis: treatment of the
cause
•Primary hydronephrosis:
• Pyeloplasty:
• Anderson- Hynes
• Culp
• Foley
• Nephrectomy 69

42. PROCEDURES FOR PRIMARY
HYDRONEPHROSIS
70

43. Anderson- Hynes Pyeloplasty
(Dismembered) :
• In this procedure , upper one third of ureter and
Renal pelvis are mobilised
• Anastamosis is made between ureteric end and
kidney
• A Nephrostomy tube was placed in order to
protect the anastamosis

46. 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 situ.
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47. 73
A spiral incision is made in the enlarged renal pelvis
and extended an equal distance into the ureter.
b | The tissue flap is turned down and stitched into
the adjacent ureter.
c | The flap is closed with fine interrupted or
running absorption sutures.

48. 74
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

50. COMPLICATIONS
• Development of a urinary tract infection (UTI).
• When the UTI is associated with a high fever, a
kidney infection is (pyelonephritis) is suspected.
This is caused by bacteria spreading from the
bladder to the kidney and invading the kidney
tissue.
• If pyelonephritis is severe or not treated in a timely
manner, or if it affects both kidneys, complications
such as permanent kidney damage (kidney scarring)
can lead to problems such as high blood pressure
and sometimes kidney failure. 77

51. ROBOT-ASSISTED
PYELOPLASTY
• A robot-assisted pyeloplasty is a minimally
invasive laparoscopic procedure. With the use
of a tiny camera, surgeons operate using very
thin instruments inserted into three or four
small incisions.
• Robot-assisted pyeloplasty removes an
obstructed section of the ureter and reattaches
the healthy portion to the kidney's drainage
system.
78

53. Thank you