HYDRONEPHROSIS
? A 32yearold pregnant woman presents to the ER with right
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sided flank pain. Renal US shows right hydronephrosis.What is the differential diagnosis?
What is the differential diagnosis?
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? Physiologic hydronephrosis.
? Dilation of the upper urinary tracts occurs by the 7th week of
gestation and may persist for 6 weeks postpartum.
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? Results from both hormonal and mechanical factors.
? Ureteral dilation is more pronounced on the right side because
of dextrorotation of the uterus, whereas the left ureter is more
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protected from compression by the gas fil ed sigmoid colon.
? How do you distinguish physiologic hydronephrosis from
intrinsic obstruction due to distal ureteral stone disease?
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? Physiological hydronephrosis typically is more on the right side
and generally terminates at the pelvic brim.
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? If the hydroureteronephrosis extends below the pelvic brim,distal ureteral obstruction should be considered.
? Imaging suggests physiologic hydronephrosis.
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How is this managed?
How is this managed?
? Analgesia
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? Positioning the patient on her left side.? Ureteral stent or nephrostomy tube
? The flank pain resolves with conservative measures and you
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see the patient in clinic 2 weeks later. Her urinalysis (UA) showsbacteriuria, but she is asymptomatic.
Should this be treated?
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Should this be treated?? Because of the risk of acute pyelonephritis.
? The rate of progression of asymptomatic bacteriuria to
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symptomatic infection is 34 times higher during pregnancy.Introduction
? Common clinical condition.
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? Defined as distention of the renal calyces and pelvis with urine as a
result of obstruction of the outflow of urine.
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? Can be physiologic or pathologic, acute or chronic, unilateral orbilateral.
? Obstructive uropathy ?
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? Functional or anatomic obstruction of urinary flow at any level of the
urinary tract.
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? Obstructive nephropathy ?? When the obstruction causes functional or anatomic renal damage.
Pathophysiology
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Interruption in the flow of urineIncreased ureteral pressure
Decreased GFR
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? This decline of GFR can persist for weeks after relief of
obstruction.
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? Decreased function of the nephrons.? The extent of functional insult is directly related to the duration
and extent of the obstruction.
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? Brief obstruction- reversible functional changes.? Chronic obstruction - profound tubular atrophy and permanent
nephron loss.
Causes of U/L obstruction
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? Extramural obstruction
Tumour from adjacent structures, e.g. carcinoma of the
cervix, prostate, rectum, colon or caecum
Idiopathic retroperitoneal fibrosis
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Retrocaval ureter? Intramural obstruction
Congenital stenosis, PUJO
Ureterocele and congenital small ureteric orifice
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StrictureNeoplasm of the ureter or bladder cancer involving the
ureteric orifice
? Intraluminal obstruction
Calculus in the pelvis or ureter
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Sloughed papil a in papil ary necrosis due to?------Causes of B/L Hydronephrosis
? congenital:
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? posterior urethral valves;? urethral atresia;
? acquired:
? benign prostatic enlargement or carcinoma of the prostate;
? postoperative bladder neck scarring;
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? urethral stricture;? phimosis.
Clinical features
? Mild pain or dull aching in the loin.
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? Palpable kidney? New onset HTN
? Recurrent UTIs
? Attacks of acute renal colic may occur with no palpable swelling.
? Intermittent hydronephrosis (Dietl's crisis).
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A swelling in the loin is associated with acute renal pain. Somehours later the pain is relieved and the swelling disappears when
a large volume of urine is passed.
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Investigations
? urine analysis
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? Assesment of renal function? USG
? Colour Doppler USG
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? CT urography
? MR urography
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? IVP? Retrograde pyelography
? Isotope renography
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? Very occasionally, a Whitaker test is indicated. A percutaneous puncture of the
kidney is made through the loin and fluid is infused at a constant rate with
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monitoring of intrapelvic pressure.Treatment
1. Pain management.
2. Renal drainage ? stenting/nephrostomy ? why?
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3. Treat the cause4. Anderson-Hynes pyeloplasty.
5. Endoscopic pyelolysis
VESICOURETERAL REFLUX
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INTRODUCTION? Characterized by the retrograde flow of urine from the bladder to
the kidneys.
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? VUR may be associated with (UTI), HDN and abnormal kidney
development (renal dysplasia).
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? Increased risk for pyelonephritis, hypertension, and progressiverenal failure.
? Early diagnosis and vigilant monitoring of VUR are the
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cornerstones of management.
CAUSES
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qPrimary causes? Short or absent intravesical ureter
? Absence of adequate detrusor backing
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? Lateral displacement of the ureteral orifice
? Paraureteral (Hutch) diverticulum
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qSecondary causes? Cystitis or UTI
? Bladder outlet obstruction
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? Neurogenic bladder
? Detrusor instability
Pathophysiology
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? Ureter inserts into the trigone.
? The intramural portion of the ureter courses into the bladder
wall at an oblique angle.
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? This intramural tunnel length?to?ureteral diameter ratio is 5:1.
? As the bladder fil s with urine and the bladder wall distends and
thins, the intramural portion of the ureter also stretches, thins
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out, and becomes compressed against the detrusor backing.
? This functions as a flap-valve mechanism and prevents urinary
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reflux.Pathophysiology
? A short intramural tunnel results in a malfunctioning flap-valve
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mechanism and VUR.
? Reflux of infected urine is responsible for the renal damage.
? bacterial endotoxins leads to release of oxygen free radicals.
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? These oxygen free radicals result in fibrosis and scarring of theaffected renal parenchyma.
Clinical features
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? No specific signs or symptoms unless complicated by UTI.? LUTS.
? Palpable kidney.
? New onset HTN.
? Renal failure.
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Workup VUR
Lab studies
? Urinalysis and urine culture.
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? RFT.? Serum electrolytes
Imaging studies
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? VCUG/radionuclear cystouretherography? USG
? Nuclear scan
? Urodynamic studies
? Cystoscopy
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Treatment? Medical treatment
? Surgical treatment
? Surveil ance
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Medical management? Administering long-term suppressive antibiotics
? Correcting the underlying voiding dysfunction (if present)
? Conducting follow-up radiographic studies (eg, VCUG, nuclear
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cystography, DMSA scan) at regular intervals
Surgical treatment
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? Grade III or more reflux.? Failure of medical management.
? Ureteral reimplantation
? Endoscopic treatment:
? The principle of the procedure is to inject, under cystoscopic
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guidance, a biocompatible bulking agent underneath the intravesical
portion of the ureter in a submucosal location.
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? The bulking agent elevates the ureteral orifice and distal ureter insuch a way that the lumen is narrowed, preventing regurgitation of
urine up the ureter but stil al owing its antegrade flow.
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A 50 year old female is admitted with abdominal painand anuria. Radiological studies reveal bilateral
impacted ureteric stones with hydronephrosis. Urine
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analysis showed RBCs with pus cells in urine. Serum
creatinine level was 16 mg / dl and blood urea level
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was 200 mmol/L; which of the following should be theimmediate treatment.
a. Lithotripsy
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b. Ureteroscopic removal of stonesc. `J' stent drainage
d. Hemodialysis