Hydronephrosis is dilatation of the kidney caused by urine outflow obstruction anywhere along the urinary tract. It can be caused by extramural factors like tumors or retroperitoneal fibrosis, or intramural factors like congenital abnormalities or inflammatory strictures. Bilateral hydronephrosis is commonly due to urethral obstruction from conditions like benign prostatic enlargement. Clinical features depend on severity and location of obstruction, and may include flank pain, urinary symptoms, or renal failure. Diagnosis involves imaging tests like ultrasound and IVU. Treatment involves relieving obstruction through stents, nephrostomy, or open surgery like pyeloplasty depending on severity and cause of obstruction.

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