AcuteHydronephrosis Clinical features Management

1. Hydronephrosis
Dr.Akmal
Associate Professor
Department of General Surgery
AVMC & H

2. • Hydronephrosis is an aseptic dilatation of the kidney caused by
obstruction.
• Dilation of renal pelvis and calycesassociated with
progressive atrophy of the kidney.
• Urine outflow obstruction.
• Obstructive uropathy indicates impedance of urinary flow
anywhere along the urinary tract and damage to renal parenchyma
due to obstruction at any site.
Definition

3. HYDRONEPHROSIS: CAUSES
Causes of Unilateral Ureteric Obstruction
Extramural obstruction:
Adjacent structures neoplasm like those of cervix, prostate, rectum,
colon or caecum
Idiopathic retroperitoneal fibrosis
Retrocaval ureter
• Intramural obstruction:
Congenital stenosis, physiological narrowing of the pelviureteric
junction leading to pelviureteric junction obstruction
Ureterocele and congenital small ureteric orifice

4. Ureterocele
Cobra head appearance of
ureterocele

5. CAUSESOF UNILATERALURETERIC
OBSTRUCTION
• Intramural obstruction:
 Inflammatory stricture following removal of ureteric
calculus, repair of a damaged ureter or tuberculous infection
 Neoplasm of the ureter or bladder cancer involving the ureteric
orifice
• Intraluminal obstruction:
 Calculus in the pelvis or ureter
 Sloughed papilla in papillary necrosis(more commonly in
• diabetics, analgesic abusers and sickle cell disease)

6. Ureteric Calculi

7. BILA
TERALHYDRONEPHROSIS
It iscommonly result of urethral obstruction.
Causes:
Congenital
 Posterior urethral valves
 Urethral atresia
Acquired
 Benign prostatic enlargement
 Carcinoma of the prostate
 Postoperative bladder neck scarring
 Urethral stricture
 Phimosis

8. Posterior Urethral Valve

11. PA
THOPHYSIOLOGY
• Even with complete obstruction, glomerular filtration persists for
some time
• Thefiltrate diffuses back to the interstitium an perirenal
spaces
• Affected calyces and pelvis becomes dilated
• High pressure transmitted through collecting ducts:
Cortex: Renal atrophy
Medulla: Renal vasculature compression with diminished
inner medullar blood flow
s
ac
• Thekidney becomes athin walled, lobulated, fluid filled

12. PATHOPHYSIOLOGY
• Effective hydroureteronephrosis on renal function depends on
whether it is totally or partially obstructive and unilateral or
bilateral
• Effects of obstruction of the kidney are time dependent.
Within several hours, changes are evident but:
1–2 week:glomerular destruction, tubular atrophy, and
interstitial fibrosis occur
By6–8 week: irreversible damage occurs

14. CLINICALFEA
TURES
Unilateral Hydronephrosis ( commonly by idiopathic
pelvicureteric junction obstruction or calculus)
• More common in women and on right side
• May remain silent for long periods, being apparent in course of imaging
studies (about 3%of population)
• Mild pain or dull aching in loin (dragging heaviness worsened by
excessivefluid intake)
• Kidney may be palpable
• Intermittent Hydronephrosis (Dietl’s crisis)

15. CLINICALFEA
TURES
Bilateral Hydronephrosis:
Dysuria,
 Loin pain
 Features of bladder outlet obstruction: Polyuria, Nocturia,
Hesitancy
 Kidneys usually not palpable
 Inability to concentrate urine which may be associated with distal
tubular acidosis, chronic tubulointerstitial nephritis, renal and renal
salt wasting

16. CLINICALFEATURES
• Complete Bilateral Obstruction:
Rapid onset oliguria or anuria that is incompatible with
survival until obstruction is relieved.After relief, post
obstructive diuresis with large amount of sodium chloride
• Ureters and pelvis dilatation in pregnancy:
Up to 20th week .Backto normal within 12 weeks of delivery
Effect of high progesterone on smooth muscles

17. POSSIBLEEXAMINATION
FINDINGS
• General condition: pain or localized symptoms
• Abdominal, flank, or pelvic mass
• Flank tenderness can occur along with acute obstruction
and with calculi or infection
• V
aginal exam– Ureteral prolapse
• Digital rectal exam– Enlarged prostate, nodularity suggestive of
prostate cancer

18. INVESTIGATIONS
• Ultrasound scanning:
least invasive, regularly used for pelviureteric junction
obstruction
• Intravenous Pyelogram:
Significant function in obstructed kidney
Contrast fills the obstructed system down to blockage
Cantake follow up films 36 hours after the injection of
contrast

19. INVESTIGATIONS
Isotope renography
 Best to confirm obstructive dilatation of collectingsystem
 Technetium 99m-labelled DTP
A (diethylenetriaminepenta- acetic
acid or MAG-3) injected intravenously and tracked using gamma
camera
 99mTc-DTP
Astays in renal pelvis in obstructed site

20. Isotope renogram series shows a late accumulation and
persistence of radioactivity in the left kidney

21. INVESTIGATIONS
Whitaker test
 Percutaneous puncture made in kidney, fluid is infused at
constant rate with monitoring intrapelvic pressure,
 Abnormal rise in intrapelvic pressure confirms obstruction
Retrograde Pyelography
 Confirms site of obstruction
 Done immediately before corrective surgery

23. TREATMENT
• Hydronephrosis is not a specific diagnosis but a finding or sign
• Management is highly dependent on underlying condition
and the timing (acute vs. chronic)
• Urgent decompression isneeded with:
– Severe pain
– Active urinary tract infection and acute kidney insufficiency
–Retrograde ureteral stent or percutaneous nephrostomy
can provide equally effective drainage

24. MEDICALTHERAPY
• Patients with infection and hydronephrosis require antibiotic
therapy and drainage
• Renal failure and electrolyte abnormalities should be
corrected in conjunction with drainage
• Along with these, catheter drainage may be required as well

25. TREATMENT
• Indications for surgery:
Bouts of renal pain
Increasing Hydronephrosis
Evidence of parenchymal damage and infection
• Mild casesfollowed by serial ultrasound scans and operated upon
if dilatation is increasing
• Nephrectomy considered only when kidney largely
destroyed

26. ANDERSONS-HYNES
PYELOPLASTY
• Upper third of ureter and renal pelvis is mobilized
• Renal vein can be divided but artery should be preserved
• Anastomosis formed in front of artery
• A nephrostomy tube or ureteric stent protects the
anastomosis
• Laparoscopic pyeloplasty, a minimal access procedure is
becoming increasingly popular

28. ENDOSCOPICPYELOPLASTY
• Disruption of pelviureteric junction by aballoon passed up
the ureter and distended under radiographic control
• Long term efficacy still need to be proved

29. THANK YOU