Urology 4: Hydronephrosis

Contents

• Definition• Etiology• Pathology• Clinical features• Special investigations• Treatment

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Definition

• Dilatation of renal pelvis & calyces with accompanying destruction of the kidney parenchyma

• Usually due to partial obstruction to the outflow of urine

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Hydronephrosis

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Normal kidney Hydronephrosis

Normal Intravenous Pyelogram (IVP)

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Intravenous Pyelogram (IVP) Showing Hydronephrosis7

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Etiology

• Primary or secondary

• Primary: idiopathic

• Secondary: maybe unilateral or bilateral

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Causes of unilateral hydornephrosis

• Maybe extramural, intramural or Intraluminal

• 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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Causes of unilateral hydornephrosis

• Maybe extramural, intramural or Intraluminal

• Intramural:– Congenital stenosis or achalasia of the PUJ– Ureterocele– Stricture– Neoplasm of ureter

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Causes of unilateral hydornephrosis

• Maybe extramural, intramural or Intraluminal

• Intraluminal:– Calculus– Congenital folds at the upper end of the ureter

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Causes of bilateral hydornephrosis

• Due to pathologies in the urethra or the urinary bladder

• Causes in the urethra:– Pin – hole meatus– Congenital valves– BPH & carcinoma of prostate– Stricture– Carcinoma of cervix & uterus

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Causes of bilateral hydornephrosis

• Due to pathologies in the urethra or the urinary bladder

• Causes in the bladder:– Calculus– Neoplasms– Sphincter dysfunction

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Pathophysiology

• Dilatation of the renal pelvis & calyces

• Types of hydronephrosis:– Pelvic type– Renal type– Pelvirenal type: most common type, both the pelvis & calyces are

equally dilated

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Clinical features

• May depend on unilateral, intermittent or bilateral hydronephrosis

• Unilateral hydronephrosis:– Dull ache & sense of weight on the affected side of the loin– Causes of the hydronephrosis

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Clinical features

• May depend on unilateral, intermittent or bilateral hydronephrosis

• Intermittent hydronephrosis:– Dietl’s crisis

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Clinical features

• May depend on unilateral, intermittent or bilateral hydronephrosis

• Bilateral hydronephrosis:– Features of the causes– Bilateral renal swelling

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Special investigations

• Straight abdomen of the X- ray• Excretory urography• Retrograde urography• Ultrasound

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Treatment

• Secondary hydronephrosis: treatment of the cause• Primary hydronephrosis:

– Pyeloplasty:• Anderson- Hynes • Culp• Foley

– Nephrectomy

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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

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extraperitoneal flank approach, bed of the twelfth rib

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