Urology 4: Hydronephrosis

Contents Definition Etiology Pathology Clinical features Special investigations Treatment 2

Definition Dilatation of renal pelvis & calyces with accompanying destruction of the kidney parenchyma Usually due to partial obstruction to the outflow of urine 3

Hydronephrosis 4

5 Normal kidneyHydronephrosis

Normal Intravenous Pyelogram (IVP) 6

Intravenous Pyelogram (IVP) Showing Hydronephrosis 7

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Etiology Primary or secondary Primary: idiopathic Secondary: maybe unilateral or bilateral 9

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 10

Causes of unilateral hydornephrosis Maybe extramural, intramural or Intraluminal Intramural: – Congenital stenosis or achalasia of the PUJ – Ureterocele – Stricture – Neoplasm of ureter 11

Causes of unilateral hydornephrosis Maybe extramural, intramural or Intraluminal Intraluminal: – Calculus – Congenital folds at the upper end of the ureter 12

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 13

Causes of bilateral hydornephrosis Due to pathologies in the urethra or the urinary bladder Causes in the bladder: – Calculus – Neoplasms – Sphincter dysfunction 14

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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 17

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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 19

Clinical features May depend on unilateral, intermittent or bilateral hydronephrosis Intermittent hydronephrosis: – Dietl’s crisis 20

Clinical features May depend on unilateral, intermittent or bilateral hydronephrosis Bilateral hydronephrosis: – Features of the causes – Bilateral renal swelling 21

Special investigations Straight abdomen of the X- ray Excretory urography Retrograde urography Ultrasound 22

Treatment Secondary hydronephrosis: treatment of the cause Primary hydronephrosis: – Pyeloplasty: Anderson- Hynes Culp Foley – Nephrectomy 23

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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 27

28 extraperitoneal flank approach, bed of the twelfth rib

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