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HYDRONEPHROSIS &

VESICOURETERAL REFLUX

Dept. Of Surgery

HYDRONEPHROSIS
? A 32yearold pregnant woman presents to the ER with right

sided flank pain. Renal US shows right hydronephrosis.

What is the differential diagnosis?

What is the differential diagnosis?

? Physiologic hydronephrosis.
? Dilation of the upper urinary tracts occurs by the 7th week of

gestation and may persist for 6 weeks postpartum.

? 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

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?

? Physiological hydronephrosis typically is more on the right side

and generally terminates at the pelvic brim.

? If the hydroureteronephrosis extends below the pelvic brim,

distal ureteral obstruction should be considered.

? Imaging suggests physiologic hydronephrosis.

How is this managed?
How is this managed?

? Analgesia
? Positioning the patient on her left side.
? Ureteral stent or nephrostomy tube

? The flank pain resolves with conservative measures and you

see the patient in clinic 2 weeks later. Her urinalysis (UA) shows

bacteriuria, but she is asymptomatic.

Should this be treated?
Should this be treated?

? Because of the risk of acute pyelonephritis.
? The rate of progression of asymptomatic bacteriuria to

symptomatic infection is 34 times higher during pregnancy.

Introduction

? Common clinical condition.

? Defined as distention of the renal calyces and pelvis with urine as a

result of obstruction of the outflow of urine.

? Can be physiologic or pathologic, acute or chronic, unilateral or

bilateral.

? Obstructive uropathy ?

? Functional or anatomic obstruction of urinary flow at any level of the

urinary tract.

? Obstructive nephropathy ?

? When the obstruction causes functional or anatomic renal damage.
Pathophysiology

Interruption in the flow of urine

Increased ureteral pressure

Decreased GFR

? This decline of GFR can persist for weeks after relief of

obstruction.

? Decreased function of the nephrons.
? The extent of functional insult is directly related to the duration

and extent of the obstruction.

? Brief obstruction- reversible functional changes.
? Chronic obstruction - profound tubular atrophy and permanent

nephron loss.
Causes of U/L obstruction

? Extramural obstruction
Tumour from adjacent structures, e.g. carcinoma of the
cervix, prostate, rectum, colon or caecum
Idiopathic retroperitoneal fibrosis
Retrocaval ureter

? Intramural obstruction
Congenital stenosis, PUJO
Ureterocele and congenital small ureteric orifice
Stricture
Neoplasm of the ureter or bladder cancer involving the
ureteric orifice
? Intraluminal obstruction
Calculus in the pelvis or ureter
Sloughed papil a in papil ary necrosis due to?------

Causes of B/L Hydronephrosis

? congenital:
? posterior urethral valves;
? urethral atresia;
? acquired:
? benign prostatic enlargement or carcinoma of the prostate;
? postoperative bladder neck scarring;
? urethral stricture;
? phimosis.
Clinical features

? Mild pain or dull aching in the loin.
? Palpable kidney
? New onset HTN
? Recurrent UTIs
? Attacks of acute renal colic may occur with no palpable swelling.
? Intermittent hydronephrosis (Dietl's crisis).
A swelling in the loin is associated with acute renal pain. Some

hours later the pain is relieved and the swelling disappears when

a large volume of urine is passed.

Investigations

? urine analysis

? Assesment of renal function

? USG

? Colour Doppler USG

? CT urography

? MR urography

? IVP

? Retrograde pyelography

? Isotope renography

? 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

monitoring of intrapelvic pressure.
Treatment

1. Pain management.
2. Renal drainage ? stenting/nephrostomy ? why?
3. Treat the cause
4. Anderson-Hynes pyeloplasty.
5. Endoscopic pyelolysis

VESICOURETERAL REFLUX
INTRODUCTION

? Characterized by the retrograde flow of urine from the bladder to

the kidneys.

? VUR may be associated with (UTI), HDN and abnormal kidney

development (renal dysplasia).

? Increased risk for pyelonephritis, hypertension, and progressive

renal failure.

? Early diagnosis and vigilant monitoring of VUR are the

cornerstones of management.

CAUSES

qPrimary causes

? Short or absent intravesical ureter

? Absence of adequate detrusor backing

? Lateral displacement of the ureteral orifice

? Paraureteral (Hutch) diverticulum

qSecondary causes

? Cystitis or UTI

? Bladder outlet obstruction

? Neurogenic bladder

? Detrusor instability
Pathophysiology

? Ureter inserts into the trigone.
? The intramural portion of the ureter courses into the bladder

wall at an oblique angle.

? 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

out, and becomes compressed against the detrusor backing.

? This functions as a flap-valve mechanism and prevents urinary

reflux.

Pathophysiology

? A short intramural tunnel results in a malfunctioning flap-valve

mechanism and VUR.

? Reflux of infected urine is responsible for the renal damage.
? bacterial endotoxins leads to release of oxygen free radicals.
? These oxygen free radicals result in fibrosis and scarring of the

affected renal parenchyma.
Clinical features

? No specific signs or symptoms unless complicated by UTI.
? LUTS.
? Palpable kidney.
? New onset HTN.
? Renal failure.

Workup VUR
Lab studies

? Urinalysis and urine culture.
? RFT.
? Serum electrolytes

Imaging studies

? VCUG/radionuclear cystouretherography
? USG
? Nuclear scan
? Urodynamic studies
? Cystoscopy
Treatment

? Medical treatment
? Surgical treatment
? Surveil ance
Medical management

? Administering long-term suppressive antibiotics
? Correcting the underlying voiding dysfunction (if present)
? Conducting follow-up radiographic studies (eg, VCUG, nuclear

cystography, DMSA scan) at regular intervals

Surgical treatment

? Grade III or more reflux.
? Failure of medical management.
? Ureteral reimplantation
? Endoscopic treatment:
? The principle of the procedure is to inject, under cystoscopic

guidance, a biocompatible bulking agent underneath the intravesical

portion of the ureter in a submucosal location.

? The bulking agent elevates the ureteral orifice and distal ureter in

such a way that the lumen is narrowed, preventing regurgitation of

urine up the ureter but stil al owing its antegrade flow.
A 50 year old female is admitted with abdominal pain

and anuria. Radiological studies reveal bilateral

impacted ureteric stones with hydronephrosis. Urine

analysis showed RBCs with pus cells in urine. Serum

creatinine level was 16 mg / dl and blood urea level

was 200 mmol/L; which of the following should be the

immediate treatment.

a. Lithotripsy
b. Ureteroscopic removal of stones
c. `J' stent drainage
d. Hemodialysis