Acute obstructive uropathy is a commonly encountered condition occurring in inpatient and

outpatient settings. Unilateral obstruction to urinary outflow typically occurs, with little if any
change in measured renal function in a healthy individual. However, the less common bilateral
form results in measurable changes in kidney function. Acute obstructive uropathy is depicted in
the scans below.

Right ureteral calculus with periureteral

stranding

Right-sided hydronephrosis secondary to mid

ureteral calculus in young female presenting with acute flank pain

Preferred examination
The advent of helical computed tomography (CT) scanning has dramatically altered the
diagnostic imaging approach to patients presenting with acute flank pain. Unenhanced helical
CT has both a high sensitivity of 95-98% and a high specificity of 96-100% in detecting ureteral
calculi in the acute setting.[1, 2, 3, 4, 5, 6] Calcified and noncalcified calculi may be identified, along
with the location and size of the stone. Secondary signs of obstructive uropathy, including
hydronephrosis, perinephric and periureteral stranding, as well as ureterectasis, are well
demonstrated on CT.[7, 8, 9]

Several reports compared unenhanced helical CT with intravenous urography (IVU), the
established criterion standard in evaluating the genitourinary system.[10, 11] CT has been shown to
be more sensitive in detecting and characterizing ureteral calculi and at least as sensitive in
demonstrating the presence of obstructive uropathy.[12]
Additionally, CT may be performed rapidly, in approximately one third the time of an IVU study,
and does not require the use of IV contrast material. The ability to diagnose noncalculus
etiologies, as well as evaluate other intra-abdominal pathologies that may mimic renal colic,
affords CT an invaluable advantage.
Levine et al reported the sensitivity of plain radiography in detecting ureteral calculi to be
approximately 45% and recommended that noncontrast helical CT replace the kidneys, ureters,
bladder (KUB) film as the initial and possibly only imaging study.[4] While CT appears to have
replaced plain radiography and IVU in the initial evaluation of acute flank pain, these modalities
remain involved in the follow-up evaluation of stone disease, as well as surgical and
interventional planning.
In the evaluation of acute flank pain, ultrasonography (US) is limited primarily to pregnant
patients.[13] While US demonstrates renal calculi, it is poor at detecting ureteral stones. Doppler
sonography has been suggested as a method of indirectly determining obstruction by
measuring the resistive index in renal arteries and evaluating the direction and magnitude of
ureteral jets.[14, 15, 16]
In nuclear medicine, the passage of radionuclide agents through the urinary tract is monitored
with a gamma camera. Outlines of the kidney and ureter are generated, and a point of
obstruction may be evident. More importantly, it provides physiologic information regarding the
function and dynamics of the urinary system. The technique of choice in the evaluation of
obstruction is diuresis renography, which is performed with technetium-99m-labeled
mercaptoacetyltriglycine (99m Tc-MAG3) in most centers.[17, 18, 19]
Diuresis renography is not performed routinely in acute ureteral colic, as CT usually provides
the necessary information. However, it may be important in documenting return of renal function
in patients for whom urologic intervention is required. Renography with Lasix is useful in
determining whether pelvocalyceal system dilatation, often observed on a screening study such
as US, is obstructive or nonobstructive in nature.
Ultrafast T1- and T2-weighted techniques such as spoiled gradient echo (T1) and single-shot
fast spin echo (T2) have been reported to be highly sensitive and specific for determining the
presence of both ureteral calculi and acute obstructive uropathy. However, as with US, in
magnetic resonance urography (MRU), the degree of dilatation must be sufficient to use the
native urine as a contrast agent.[20, 21]

Limitations of techniques
An inherent limitation of unenhanced helical CT is in providing functional information. The
severity of obstruction may be inferred by the presence of perinephric stranding, which is
believed to result from forniceal rupture or inflammation in the perirenal fat from high calyceal
pressures. The absence of this finding, as well as the other signs of obstruction, does not
exclude a significant obstruction.
Performing a contrast-enhanced CT may provide greater physiologic information by
demonstrating an obstructive nephrogram and pyelosinus extravasation of contrast material. An
important consideration in choosing this modality is the significant radiation dose to the patient,

compared to an intravenous pyelogram (IVP). This disadvantage restricts its use, especially in
pregnant and pediatric patients.
It has been reported that in patients with ureteral calculi, stone size alone determines initial
treatment of patients, with no correlation found between severity of obstruction as suggested by
CT and the decision to treat conservatively or perform an intervention. The authors therefore
suggest that nonenhanced helical CT is adequate for the initial diagnosis and treatment of
patients with stone disease.
Plain radiography and IVU have similar drawbacks, including lower sensitivity because of
superimposition of bone and other calcified structures and obscuring bowel pattern. They are
limited by stone size (< 4 mm) and patient habitus. IVU, although providing both anatomic and
physiologic information, has the added disadvantage of being time consuming and dependent
on administration of contrast material, with its potential complications. It is also dependent on
renal function, as the use of the test is greatly diminished when the serum creatinine
concentration is elevated when the patient has both intrinsic renal disease and an acute
obstruction.
US evaluates the ureters and detects calculi poorly. The accuracy of US in diagnosing
obstruction in the setting of acute flank pain was found to be approximately 66%. This is directly
related to the anatomic nature of the examination, which relies mainly on the presence of
hydronephrosis to make the diagnosis. In early obstruction, up to 36 hours after onset, no
dilatation of the collecting system may be present, and a false-negative study may result.
Doppler sonography is operator dependent and time consuming. Determination of ureteral jets
and the resistive index has not been adopted into widespread clinical use for acute obstruction
because of technical limitations and questionable accuracy. Most pathologic processes
decrease renal perfusion and thus increase the resistive index (RI).
Diuresis renography, a physiologically driven study, depends on renal function. If marked
impairment of bilateral renal function is present, an indeterminate study results. In patients who
are dehydrated, the expected response to the diuretic may not be evident, leading to an
inconclusive study.
The use of MRU in the acute setting of flank pain also is limited. Studies comparing MRU to CT
and IVU reveal that MRU misses small calculi and mild dilatation. In addition, it is time
consuming and expensive and is limited to special situations, such as pregnant patients.

Special concerns
Calculi may be missed and signs of obstruction may not be evident. Clinical and imaging followup care is warranted to prevent the loss of kidney function. The interpreting radiologist is
responsible for all pathologic entities present on the imaging study, whether or not they may be
the source of the present symptoms.
The diagnostic imaging approach to these patients begins with an abdominal US to demonstrate
the presence of hydronephrosis. Remember that mild hydroureteronephrosis is observed in
normal pregnant patients. Transvaginal and transrectal US may be used to detect distal ureteral
calculi. Doppler sonography plays an important role, using the RI and ureteral jets to diagnose
obstruction.
Where US does not provide a diagnosis, MRU or IVU may be the next step in imaging. MRU, if
available, is preferred, as no ionizing radiation exposure occurs. One can make the diagnosis of

an obstructing calculus by the presence of a filling defect with associated perinephric or

periureteral edema.
Alternatively, an extremely limited IVU may provide the necessary information. The limited IVU
consists of a preliminary film followed by a single postcontrast exposure to demonstrate the
point and cause of obstruction. However, the gravid uterus with the fetus can obscure a
nonpregnancy cause of hydronephrosis.

Radiography
The plain abdominal radiograph or KUB film has long been the initial imaging study of choice in
patients presenting with symptoms of acute flank pain. Calculi may have a variable appearance
on radiographs depending on their chemical composition, especially the percentage and
distribution of calcium within them. They may appear homogeneously dense and smooth to
laminated and jagged. The radiographic characteristics of acute obstructive uropathy are
demonstrated in the images below.

Kidneys, ureters, bladder (KUB) film showing

right staghorn calculus and small left proximal ureteral calculus

Delayed intravenous pyelogram (IVP) film

with right staghorn calculus and obstructive nephrogram on the left, from a stone lodged in the proximal ureter

While 90% of stones contain calcium, the sensitivity of plain films has been reported at only 5060%, with a specificity of 70%. Therefore, in many centers, plain radiographs are deferred in
favor of CT in the acute setting. In some instances, renal and ureteral calculi are detected on
plain abdominal radiographs obtained for another reason.
Most noncalcified stones, blood clots, and most other intraluminal obstructive causes are
radiolucent; therefore, they are not seen on abdominal radiographs. In trauma, the presence of
pelvic fractures and soft-tissue mass in the abdomen or pelvis may alert the radiologist to the
possibility of ureteral injury, a rare complication, or obstruction from a large hematoma.
IVU, also termed excretory urography, came into clinical existence in the 1920s as a method of
evaluating the structure and function of the kidney and urinary tract. It served as a screening
study and a diagnostic imaging study in patients with acute renal or ureteral colic, demonstrating
calculi and the presence of obstruction fairly accurately.
Since 1995, noncontrast helical CT has superseded IVU in this setting, at least as a screening
study. Obstructive uropathy demonstrated on unenhanced helical CT often requires no further
imaging studies. An estimated 15% of helical CT studies require radiopaque contrast media to
confirm or exclude pelvic calcifications as stones or phleboliths.[22] However, IVU may be
performed if findings are equivocal or a noncalculus etiology is suggested.
IVU begins with a scout or preliminary radiograph. Additionally, oblique scout radiographs may
be obtained. Preinjection linear tomograms are helpful when the bowel pattern obscures the
areas of interest. Following the administration of the contrast agent, coned films and tomograms
are then obtained, with the intervals and total number of films being quite variable. In a normal
kidney, opacification of the renal parenchyma is observed within 1 minute. Within the next 2
minutes, the pelvocalyceal system may be seen, followed by the ureters approximately 5-10
minutes postinjection.

In an obstructed kidney, delayed accumulation of contrast is seen, resulting in a nephrogram

that is initially of lower density. Progressive concentration of contrast within the renal cortex and
medulla occurs, producing the classically described "obstructive nephrogram" that may persist
for some duration. Striations may occasionally be seen in the parenchyma, representing
contrast material within dilated tubules.
The pelvocalyceal system may not opacify for hours or at all, depending on the severity of
obstruction. Dilatation proximal to the obstructing process may be seen as hydronephrosis and
hydroureter, which may be minimal in the acute situation. A standing column of contrast may be
observed proximal to the obstruction. Pyelosinus extravasation of contrast and mild clubbing of
the calyces also may be seen.

Degree of confidence
Degree of confidence in interpreting plain film in acute obstructive uropathy depends on the
etiology. Determining the presence of calculi depends on multiple factors, including the size of
the stone, chemical composition, location, and multiplicity. Equally important are the technical
factors involved in obtaining an optimal radiograph. Further imaging is required when calculi are
observed, to confirm their presence and determine if signs of obstruction exist.
On an IVU, the findings of a persistent nephrogram and delayed passage of contrast through
the urinary system indicate with a high degree of confidence that an obstruction is present. IVU
is best performed following a screening study that produces either negative or equivocal results.

False positives/negatives
Both false positives and false negatives are quite common, as the sensitivity and specificity of
plain radiographs are poor. Small calcified stones, radiolucent stones, clots, and mucosal
edema are not visualized. In addition, a large patient body habitus and overlying bowel may
obscure even densely calcified stones, resulting in a false-negative interpretation.
Most false positives occur because of the presence of other calcific densities within the
perceived or expected areas of the kidney and ureter. While gallstones usually are multiple and
have a faceted appearance, they may be seen overlying the right kidney and, even on oblique
films, may be indistinguishable from renal calculi. In the pelvis, phleboliths often are
misinterpreted as ureteral calculi. The radiolucent center of a phlebolith may not always be
present to help differentiate the two.
As reported in the literature, IVU sensitivity in the evaluation of acute flank pain varies from 5287%. The detection of calculi as a cause of obstructive uropathy depends on multiple factors,
including stone size and location, as well as the degree of obstruction. As a result, falsenegative studies are not uncommon in the urographic evaluation of calculi.
The presence of a standing column of contrast does not always indicate the site of obstruction,
as it may be seen in normal individuals.

Computed Tomography
On unenhanced helical CT, calcified calculi appear as opaque densities within the genitourinary
tract, as in radiographs. Interestingly, calculi that are radiolucent on plain film also are of high
attenuation on CT. Researchers have reported that Hounsfield values may be used to
differentiate the types of calculi, as this can provide the clinician information concerning an
underlying metabolic disorder as well as influence treatment decisions. However, the overlap in

Hounsfield values among the different stones makes this of limited use.[23, 24, 25, 26, 8] Enhanced CT
scans of acute obstructive uropathy are demonstrated below.

Contrast-enhanced CT showing calculus at

left ureterovesical junction

Left ureterectasis secondary to a distal

ureteral stone

These values become important in determining the presence of an intraluminal blood clot, which
appears dense on CT but has a lower attenuation value than calculi. An exception to the normal
high attenuation of calculi has been described in a small percentage of HIV-positive patients
being treated with indinavir, a protease inhibitor.[27] As the stones are of soft-tissue attenuation,
they are not detected on noncontrast-enhanced CT.
As mentioned previously, unenhanced helical CT is not a physiologic imaging study, and the
sole finding of a stone is inadequate to make the diagnosis of obstruction. Therefore, secondary
signs of obstruction, as detected on CT, are necessary to confirm the diagnosis and obtain an
idea concerning the severity of obstruction. In the presence of ureteral calculi, proximal
ureterectasis is the most commonly seen indirect sign. This also may be observed with other
causes of intraluminal obstruction.

Dilatation of the pelvocalyceal system is seen on CT as anterior and medial bulging of the renal
pelvis, which is of low attenuation compared to the surrounding renal parenchyma. Renal
enlargement also may be observed in some patients. Perinephric fat stranding, representing
engorged lymphatics and/or edema, is seen as linear wispy densities in the normally lowattenuation fat. Moderate-to-severe perinephric stranding generally corresponds to the degree
of obstruction present.
Periureteral stranding densities often are seen, again representing edema in the surrounding
fat. Other signs of obstruction include the rim sign, which refers to the soft-tissue attenuation
halo around an intraureteral calculus, ureteral wall edema, and blurring of the renal sinus fat.
One or more of these secondary signs usually is present, and the predictive values of the
individual signs have been reported in the literature. Ureterectasis, hydronephrosis, and
periureteral and perinephric stranding each have a positive predictive value of approximately
90%.
Hydronephrosis and perinephric stranding may be the only signs of obstruction in patients with
inadvertent ligation of the ureters, while the presence of an intra-abdominal hematoma in a
posttraumatic setting or an inflammatory mass in a patient with abdominal pain indicates a
possible etiology.
The administration of IV contrast material in the above situations may help to delineate the
ureter and determine whether the obstruction is indeed secondary to extrinsic compression. In
many patients, IVU or direct visualization of the urinary tract is needed to establish the
diagnosis.
Contrast-enhanced CT in obstruction produces findings similar to that first described with IVU,
revealing a prolonged parenchymal phase. The persistent nephrogram, in which the kidney
appears with either a homogeneous or mottled density, results from delayed passage of
contrast into the collecting system. Pyelosinus extravasation is well demonstrated on CT as
areas of contrast material within the renal sinus fat.

Degree of confidence
Degree of confidence in interpreting an unenhanced helical CT in a patient with a ureteral stone
depends on the presence of secondary signs of obstruction. Ureterectasis and perinephric
stranding, when present together, have a positive predictive value of 99%. With other causes,
secondary signs of obstruction increase the confidence in making the diagnosis, although a
clear-cut cause may not be evident.

False positives/negatives
The largest source of false-positive errors in unenhanced helical CT results from phleboliths in
the pelvis. On CT, the radiolucent center is not present to help differentiate them from stones,
and some stones have a lucent center. The false-positive rate in most studies is approximately
4%. Administration of IV contrast may help by outlining the ureter and separating it from
extraluminal densities.
The absence of secondary signs of obstruction, as may occur in early obstruction, can result in
a false-negative study, especially when no intraluminal or extraluminal cause may be seen. The
incidence of false negatives is reported to be 0-6%.

Magnetic Resonance Imaging

As previous mentioned, ultrafast T1- and T2-weighted techniques such as spoiled gradient echo
(T1) and single-shot fast spin echo (T2) have been reported to be highly sensitive and specific
for determining the presence of ureteral calculi and acute obstructive uropathy. However, as
with US, in magnetic resonance urography (MRU), the degree of dilatation must be sufficient to
use the native urine as a contrast agent. (See the images below.)[20, 21, 28, 26, 29]

Dilated collecting system on left seen on MRI

Left-sided hydroureter and hydronephrosis

secondary to distal ureteral obstruction

Degree of confidence
The use of MRU in the acute setting of flank also is limited. Studies comparing MRU to CT and
IVU reveal that MRU misses small calculi and mild dilatation. In addition, it is time consuming
and expensive and is limited to special situations, such as pregnant patients.
For nephrourographic techniques and applications, see Kalb et al[30] and Akgun et al.[31]

Ultrasonography

The hallmark of obstruction on US is the presence of hydronephrosis. Prominent anechoic

structures within the renal sinus represent a dilated pelvocalyceal system. Renal calculi also
may be demonstrated as echogenic foci with or without shadowing. This finding depends on the
size of the calculi, with smaller stones blending into the echogenic renal sinus. Ureteral calculi
and ureterectasis are detected less often. While UPJ and UVJ stones may be observed, mid
ureteral stones are extremely difficult to detect. The ultrasonographic characteristics of acute
obstructive uropathy are demonstrated below.

Pelvocalyceal system dilation from

ureteropelvic obstruction

Ureterovesical junction calculus seen on

abdominal ultrasound using the bladder as an acoustic window

The reported sensitivity of US in the detection of a ureteral stone and associated obstruction is
60-70%. As a result, US is not routinely used in the evaluation of acute renal or ureteral colic.
However, it is an important screening examination in pregnant patients with acute flank pain and
in acute renal failure.[32, 33] The gravid uterus causes ureteric obstruction, and a ureteric stone
may be missed

Doppler sonography is an additional tool that may be employed when radiation exposure is
undesirable, such as in pregnant patients. The RI, which is a measure of impedance to renal
blood flow, may be raised when obstruction to urine outflow exists. In most centers, obstruction
is indicated by an RI greater than 0.70 or a difference of greater than 0.10 between the kidneys.
However, any process causing decreased perfusion will result in an elevated RI. Ureteral jets
also may be evaluated; these may be absent or decreased in frequency in acute obstruction.

Degree of confidence
US has inherent limitations that restrict its use in patients with symptoms of acute renal or
ureteral colic. Even in those patients in whom it is used, further imaging often is required for
confirmation and characterization of the obstruction.

False positives/negatives
The presence of obstruction is inferred by visualizing a dilated collecting system. This may be
minimal or even absent in acute obstruction. In addition, ureteral calculi are not well
demonstrated. The false-negative rate is as high as 35% in patients with uropathy secondary to
a calculus lodged in the ureter. Technical limitations to the study, such as patient obesity, bowel
gas, and operator skill, also may result in a false-negative study.
The false-positive rate is approximately 10% in patients with urolithiasis. The source of such
errors includes vascular calcifications that may simulate a calculus. Peripelvic cysts, an
extrarenal pelvis, or even a normal collecting system may be misinterpreted as representing
hydronephrosis. Doppler sonography can help by readily distinguishing renal hilar vessels from
a slightly dilated collecting system.

Nuclear Imaging
Scintiscans and time-activity curves before and after administration of a diuretic (furosemide)
are obtained over a period of approximately 35 minutes. In a normal renogram, initial increased
activity is seen as tracer accumulates within the kidney. As tracer moves into the collecting
system and ureter, the activity in the kidney starts to drop. In kidneys with dilated collecting
systems, an up-slope in the time-activity curve occurs as tracer is retained within the kidney.[19]
Administration of furosemide in a nondilated kidney results in a washout of tracer activity from
the collecting system, reflected as a down-slope on the time-activity curve. T is defined as the
time taken for reduction of activity by 50%; a normal T is less than 10 minutes with99m TcMAG3.
In a kidney with collecting system dilatation, a decrease in activity with furosemide indicates a
nonobstructive cause of dilatation. In an obstructed kidney, no response is observed following
the injection of furosemide. A prolonged T greater than 20 minutes is highly indicative of
obstruction. In addition, the scintiscans, while providing the data for the time-activity curve, also
may indicate the site of obstruction, past which little or no activity is seen.

Degree of confidence
Diuresis renography is accepted as a useful examination in distinguishing obstructive from
nonobstructive urinary tract dilatation, especially when collecting system dilatation has been
detected on another imaging study. In general, it correlates with findings at surgery and ureteral
perfusion studies.

To make this study definitive, renal function must be at least partially preserved. The glomerular
filtration rate (GFR) must be greater than 15 mL/min for an obstructive time-activity curve to be
judged accurate. In patients where the GFR is less than 15 mL/min, no response to the
administration of furosemide is observed. No washout of activity occurs regardless of the
presence or absence of obstruction. Thus, the study is deemed indeterminate and further
workup or intervention is required to make the diagnosis.

False positives/negatives
False-positive results are encountered predominantly as a result of impaired renal function and
overly compliant collecting systems. Both result in a delayed washout phase, leading to the
erroneous diagnosis of obstruction. In addition, use of an inadequate dose of diuretic may lead
to a similar conclusion.
The incidence of false-negative findings is lower and may result from a noncompliant collecting
system. In a partially obstructed urinary tract, the high-flow state following diuretic administration
may overcome the obstruction, resulting in a normal-appearing time-activity curve.

Background
Hydronephrosis and hydroureter are common clinical conditions encountered not only by
urologists but also by emergency medicine specialists and primary care physicians.
Hydronephrosis is defined as distention of the renal calyces and pelvis with urine as a result of
obstruction of the outflow of urine distal to the renal pelvis. Analogously, hydroureter is defined
as a dilation of the ureter.
The presence of hydronephrosis or hydroureter can be physiologic or pathologic. It may be
acute or chronic, unilateral or bilateral. It can be secondary to obstruction of the urinary tract, but
it can also be present even without obstruction.
Obstructive uropathy refers to the functional or anatomic obstruction of urinary flow at any level
of the urinary tract. Obstructive nephropathy is present when the obstruction causes functional
or anatomic renal damage. Thus, the terms hydronephrosis and obstruction should not be used
interchangeably.
The etiology and presentation of hydronephrosis and/or hydroureter in adults differ from that in
neonates and children. Anatomic abnormalities (including urethral valves or stricture, and
stenosis at the ureterovesical or ureteropelvic junction) account for the majority of cases in
children. In comparison, calculi are most common in young adults, while prostatic hypertrophy
or carcinoma, retroperitoneal or pelvic neoplasms, and calculi are the primary causes in older
patients.[1, 2]
Hydronephrosis or hydroureter is a normal finding in pregnant women. The renal pelvises and
caliceal systems may be dilated as a result of progesterone effects and mechanical
compression of the ureters at the pelvic brim. Dilatation of the ureters and renal pelvis is more
prominent on the right side than the left side and is seen in up to 80% of pregnant women.
[3]
These changes can be visualized on ultrasound examination by the second trimester, and
they may not resolve until 6-12 weeks post partum.

Pathophysiology
Hydronephrosis can result from anatomic or functional processes interrupting the flow of urine.
This interruption can occur anywhere along the urinary tract from the kidneys to the urethral
meatus. The rise in ureteral pressure leads to marked changes in glomerular filtration, tubular
function, and renal blood flow. The glomerular filtration rate (GFR) declines significantly within
hours following acute obstruction. This significant decline of GFR can persist for weeks after
relief of obstruction. In addition, renal tubular ability to transport sodium, potassium, and protons
and concentrate and to dilute the urine is severely impaired. The extent and persistence of
these functional insults is directly related to the duration and extent of the obstruction. Brief
disruptions are limited to reversible functional disturbance with little associated anatomic
changes. More chronic disruptions lead to profound tubular atrophy and permanent nephron
loss.
Increased ureteral pressure also results in pyelovenous and pyelolymphatic backflow. Gross
changes within the urinary tract similarly depend on the duration, degree, and level of
obstruction. Within the intrarenal collecting system, the degree of dilation is limited by
surrounding renal parenchyma. However, the extrarenal components can dilate to the point of
tortuosity.
To distinguish acute and chronic hydronephrosis, one may consider acute as hydronephrosis
that, when corrected, allows full recovery of renal function. Conversely, chronic hydronephrosis

is a situation in which the loss of function is irreversible even with correction of the obstruction.
Early experiments with dogs showed that if acute unilateral obstruction is corrected within 2
weeks, full recovery of renal function is possible. However, after 6 weeks of obstruction, function
is irreversibly lost.
Grossly, an acutely hydronephrotic system can be associated with little anatomic disturbance to
renal parenchyma. On the other hand, a chronically dilated system may be associated with
compression of the papillae, thinning of the parenchyma around the calyces, and coalescence
of the septa between calyces. Eventually, cortical atrophy progresses to the point at which only
a thin rim of parenchyma is present. Microscopic changes consist of dilation of the tubular
lumen and flattening of the tubular epithelium. Fibrotic changes and increased collagen
deposition are observed in the peritubular interstitium.

Epidemiology
Frequency
United States
An autopsy series of 59,064 subjects ranging in age from neonates to geriatric persons reported
hydronephrosis in 3.1%.[4] In this series, differences based on sex did not become apparent until
age 20 years. At age 20-60 years, hydronephrosis was more common in women, which was
suggested to be due to pregnancy and gynecologic malignancy. In men, prostatic diseases were
indicated as the cause of the rise in prevalence after age 60 years. Autopsy studies also
indicate that hydronephrosis is present in 2-2.5% of children.[4] The prevalence is slightly
increased in boys, most of whom in the study were younger than 1 year.
These occurrence rates likely underestimate the prevalence because conditions such as
temporary obstruction due to prior pregnancy or calculi were not included.

Mortality/Morbidity
Long-standing hydronephrosis may be associated with obstructive nephropathy and renal
failure. Patients with complete or severe partial bilateral obstruction also may develop acute or
chronic renal failure. In the latter setting, the patient is often asymptomatic and the urinalysis
results may be relatively normal or reveal only a few white or red blood cells.[5] Thus, urinary
tract obstruction should be considered in all patients with otherwise unexplained renal
insufficiency. The history may be helpful in some cases, possibly revealing symptoms of
prostatic enlargement or prior malignancy or renal calculi.
Urinary stasis may result in infection, renal scarring, calculus formation, and sepsis.
Hypertension is occasionally induced by obstruction. The mechanism responsible for the
elevation in blood pressure varies with the duration and type of obstruction. What remains
unclear, however, is why the factors described below result in hypertension in only a minority of
obstructed patients:

Acute, unilateral obstruction can cause hypertension via activation of the reninangiotensin system; renal vein renin studies lateralize the increase in renin secretion to the
obstructed kidney, a finding similar to that in unilateral renal artery stenosis. [6]
Renin secretion is usually normal in patients with bilateral urinary tract obstruction or
obstruction of a solitary functioning kidney. [6] In this condition, renal failure leading to volume

expansion is typically present; the elevation in blood pressure is probably volume mediated
and resolves with the diuresis following correction of the obstruction.

The plasma renin activity is also typically normal in chronic unilateral obstruction, and
the presence of the contralateral healthy kidney prevents both renal failure and fluid
retention. [6] Furthermore, relief of the obstruction may not correct the hypertension. These
observations suggest that the kidney may have incurred some permanent damage and that
the elevation in blood pressure is unrelated to the renal disease.
Sex
In women, gynecologic cancers and pregnancy are common causes. As such, among younger
patients (aged 20-60 y), the frequency of hydronephrosis is higher in women than in men.
In men, obstruction secondary to prostatic hypertrophy and prostate cancer are the major
causes of hydronephrosis. Consequently, among older patients (>60 y), the frequency of
hydronephrosis is higher in men than in women.

Age
In young adults, calculi are the most common causes of hydroureter and hydronephrosis.
In children and in neonates, the relative frequency of the causes of antenatal hydronephrosis
has been determined to be as follows:

Transient - 48%
Physiologic -15%
Ureteropelvic junction obstruction - 11%
Vesicoureteral reflux - 9%
Megaureter - 4%
Multicystic dysplastic kidney - 2%
Ureterocele - 2%
Posterior urethral valves - 1%

History
Adult hydronephrosis and hydroureter
Symptoms vary depending on whether the hydronephrosis is acute or chronic.
With acute obstruction, pain is frequently present, due to distention of the bladder, collecting
system, or renal capsule. Pain is typically minimal or absent with partial or slowly developing
obstruction (as with congenital ureteropelvic junction [UPJ] obstruction or a pelvic tumor). It is
not uncommon, for example, to see an adult who is noted to have hydronephrosis due to
previously unsuspected UPJ obstruction.
In comparison, relatively severe pain (renal or ureteral colic) may be seen with acute complete
obstruction (as with a ureteral calculus) or when acute dilatation occurs after a fluid load that
increases the urine output to a level greater than the flow rate through the area of obstruction.
An example of the latter problem occurs after beer drinking in a college student with previously
asymptomatic and unsuspected UPJ obstruction.

The site of obstruction determines the location of pain. Upper ureteral or renal pelvic lesions
lead to flank pain or tenderness, whereas lower ureteral obstruction causes pain that may
radiate to the ipsilateral testicle or labia.
With regard to renal insufficiency, patients with complete or severe partial bilateral obstruction
also may develop acute or chronic renal failure. In the latter setting, the patient is often
asymptomatic and the urinalysis results may be relatively normal or reveal only a few white or
red blood cells.[1]
Anuria may be a presenting symptom of the patient. Although the urine volume could be
reduced in any form of renal disease, anuria is most often seen in 2 conditions: complete
bilateral urinary tract obstruction and shock. Other less common causes of anuria are hemolyticuremic syndrome, renal cortical necrosis, bilateral renal arterial obstruction, and crescentic or
rapidly progressive glomerulonephritis, particularly antiglomerular basement membrane (GBM)
antibody disease. Bilateral symmetrical hydronephrosis usually suggests a cause related to the
bladder, such as retention, prostatic blockage, or severe bladder prolapse.
Considerations include the following:

A history of hematuria may herald a stone or malignancy anywhere in the urinary tract
A history of fever or diabetes adds urgency to the evaluation and treatment
Hydronephrosis in a patient with a solitary kidney is an emergent situation
Hydronephrosis may develop silently, without symptoms, as the result of advanced
pelvic malignancy or severe urinary retention from bladder outlet obstruction.
Pediatric hydronephrosis and hydroureter
Fetal hydronephrosis is a readily diagnosed finding on antenatal ultrasound examination and
can be detected as early as the 12th to 14th week of gestation.[7]
Although renal pelvic dilatation is a transient, physiologic state in most cases, urinary tract
obstruction and vesicoureteral reflux (VUR) are also causal. Most cases of antenatal
hydronephrosis are not clinically significant and can lead to unnecessary testing of the newborn
baby and anxiety for patients and healthcare providers.

Physical
Physical findings include the following:

With severe hydronephrosis, the kidney may be palpable.

With bilateral hydronephrosis, lower extremity edema may occur. Costovertebral angle
tenderness on the affected side is common.

A palpably distended bladder adds evidence of lower urinary tract obstruction.

A digital rectal examination should be performed to assess sphincter tone and to look for
hypertrophy, nodules, or induration of the prostate.
In children, the physical examination, especially in a newborn, can help detect abnormalities
that suggest genitourinary abnormalities associated with antenatal hydronephrosis. These
include the following:

The presence of an abdominal mass could represent an enlarged kidney due to

obstructive uropathy or multicystic dysplastic kidney (MCDK).
A palpable bladder in a male infant, especially after voiding, may suggest posterior
urethral valves.

A male infant with prune belly syndrome will have deficient abdominal wall musculature
and undescended testes. The presence of associated anomalies should be noted.
The presence of outer ear abnormalities is associated with an increased risk of
congenital anomalies of the kidney and urinary tract (CAKUT).
A single umbilical artery is associated with an increased risk of CAKUT, particularly VUR.

Causes
A multitude of causes exist for hydronephrosis and hydroureter. Classification can be made
according to the level within the urinary tract and whether the etiology is intrinsic, extrinsic, or
functional.

Ureter
Intrinsic ureter-level causes can be as follows:

Ureteropelvic junction stricture

Ureterovesical junction obstruction
Papillary necrosis
Ureteral folds
Ureteral valves
Ureterovesical reflux
Ureteral stricture (iatrogenic)
Blood clot
Benign fibroepithelial polyps
Ureteral tumor
Fungus ball
Ureteral calculus
Ureterocele
Endometriosis
Tuberculosis
Retrocaval ureter
Functional ureter-level causes can be as follows:

Gram-negative infection
Neurogenic bladder
Extrinsic ureter-level causes can be as follows:

Retroperitoneal lymphoma
Retroperitoneal sarcoma
Cervical cancer
Prostate cancer
Retroperitoneal fibrosis
Aortic aneurysm
Inflammatory bowel disease
Ovarian vein syndrome
Retrocaval ureter
Uterine prolapse
Pregnancy
Iatrogenic ureteral ligation
Ovarian cysts
Diverticulitis

Tuboovarian abscess
Retroperitoneal hemorrhage
Lymphocele
Pelvic lipomatosis
Radiation therapy
Urinoma
Bladder
Intrinsic bladder-level causes can be as follows:

Bladder carcinoma
Bladder calculi
Bladder neck contracture
Cystocele
Primary bladder neck hypertrophy
Bladder diverticula
Functional bladder-level causes can be as follows:

Neurogenic bladder
Vesicoureteral reflux
Extrinsic bladder-level causes can include pelvic lipomatosis.

Urethra
Intrinsic urethra-level causes can be as follows:

Urethral stricture
Urethral valves
Urethral diverticula
Urethral atresia
Labial fusion
Hypospadias and epispadias
Extrinsic urethra-level causes can be as follows:
Benign prostatic hyperplasia
Prostate cancer
Urethral and Penile cancer
Phimosis

Diagnostic Considerations
Other problems to consider in the differential diagnosis include the following:

Peripelvic cyst
Congenital megacalices
Calyceal diverticula
Capacious extrarenal pelvis<>
High urine flow
Pyelonephritis

Laboratory Studies
Urinalysis is used to assess for signs of infection. Pyuria suggests the presence of infection.
Microscopic hematuria may indicate the presence of a stone or tumor.
Complete blood cell count may reveal leukocytosis, which may indicate acute infection.
Serum chemistry studies can reveal an elevation of BUN and creatinine levels, which may be
the result of bilateral hydronephrosis and hydroureter. In addition, hyperkalemia can be a lifethreatening condition.

Imaging Studies
Imaging in adults
Early diagnosis of urinary tract obstruction is important because most cases can be corrected
and a delay in therapy can lead to irreversible renal injury.
Bladder catheterization should be performed initially if there is reason to suspect that bladder
neck obstruction leading to acute or chronic urinary retention may be present. Possible clues to
this diagnosis include suprapubic pain, a palpable bladder, or unexplained renal failure in an
older man.
Radiologic tests are generally used to exclude obstruction at the level of the ureters or above by
detecting dilatation of the collecting system. It is important to remember, therefore, that
obstruction can occur without dilatation in the following three settings:

Within the first 1-3 days, when the collecting system is relatively noncompliant and less
likely to dilate: In this setting, unilateral obstruction can usually be diagnosed by duplex
Doppler ultrasonography, which detects an increased resistive index (a reflection of increased
renal vascular resistance) in the affected compared with the contralateral kidney. [8] This test is
of no value with bilateral involvement because it cannot distinguish obstruction from intrinsic
renal disease.

When the collecting systems are encased by retroperitoneal tumor or fibrosis: In this
setting, hydronephrosis may be present in the absence of ureteral dilatation. Retroperitoneal
fibrosis can occur in a number of settings, including retroperitoneal fibrosis (most commonly
idiopathic or associated with beta-blocker or methysergide use, malignancy, or a connectivetissue disorder) and with the fibrotic reaction that surrounds a renal transplant. [9]Thus, the
diagnosis of renal insufficiency due to asymptomatic obstruction in a transplanted kidney may
be made based on renal biopsy findings, which show diffuse tubular dilatation, rather than the
signs of rejection or cyclosporine nephrotoxicity.

When the obstruction is mild, a setting in which renal function is not usually impaired
Renal ultrasonography is the test of choice to exclude urinary tract obstruction, avoiding the
potential allergic and toxic complications of radiocontrast media.[10] It can, in the majority of
affected patients, help diagnose hydronephrosis and establish its cause; it can also detect other
causes of renal disease such as polycystic kidney disease.
Although ultrasound can accurately identify hydronephrosis, it is less sensitive than computed
tomography (CT) for detecting stones in the ureters. In one study, hydronephrosis on ultrasound
had a positive predictive value of 0.77 for the presence of a ureteral stone and a negative
predictive value of 0.71 for the absence of a ureteral stone.[11]
Indications for CT scanning include the following:

Ultrasonography results are equivocal

The kidneys cannot be well visualized
The cause of the obstruction cannot be identified
The combination of a plain film of the abdomen (including tomographic cuts to detect
radiopaque calculi), ultrasonography, and, if necessary, CT scanning is adequate for diagnostic
purposes in over 90% of cases.[12] It should be noted, however, that the false-positive rate for
ultrasonography may be as high as 25% if only minimal criteria (any visualization of the
collecting systems) are used to diagnose obstruction.
advantages in relation to ultrasonography. The false-positive rate is very low, it can identify the
site of obstruction, and it can help detect associated conditions such as papillary necrosis or
calyceal blunting from previous infection.[12]Disadvantages are that IVP is more cumbersome to
perform and requires the administration of a radiocontrast agent. On balance, IVP can be used
to screen for urinary tract obstruction in the following settings:

In patients with staghorn calculi or multiple renal or parapelvic cysts, since

hydronephrosis is usually not distinguishable from cysts or stones by ultrasonography or CT

When CT scanning cannot identify the level of obstruction

With suspected acute obstruction due to kidney stones (or less frequently, to other
problems, such as a sloughed papilla or blood clot): Dilatation of the collecting system may not
be seen at this time, but the presence and location of the obstructing stone can be identified
Diffusion-weighted magnetic resonance imaging (MRI) may allow noninvasive detection of
changes in renal perfusion and diffusion that occur during acute ureteral obstruction.[13] The
advantage of this technique is that it does not require the use of contrast agents. However, the
clinical utility of diffusion-weighted MRI has not been adequately tested.
Hydronephrosis without apparent obstruction or with asymptomatic obstruction
In some cases, one of the above radiologic tests demonstrates hydronephrosis without
evidence of obstruction. This is a normal finding in pregnant women. Megaureter due to
previous marked vesicoureteral reflux or a dilated but nonobstructed extrarenal pelvis is the
most common example of this problem. These patients are often being evaluated for back or
flank pain, and the following two questions need to be answered:

Is obstruction present?
Is the obstruction responsible for the pain?
In this setting, 3 different tests have been used, and these are diuretic renography, IVP (less
often), and perfusion pressure flow studies.[1]
Diuretic renography involves the administration of a loop diuretic (eg, 0.5 mg/kg of furosemide)
prior to radionuclide renal scanning or during IVP, while the latter involves percutaneous
insertion of a catheter into the dilated renal pelvis, followed by fluid perfusion into the pelvis at a
rate of 10 mL/min. The marked increase in urine flow should, if obstruction is present, slow the
rate of washout of the radioisotope during renal scanning, further increase the size of the
collecting system on IVP, or elevate the renal pelvic pressure to above 22 mm Hg during a
perfusion study. Furthermore, any of these procedures may precipitate pain similar to the
patient's initial complaint.
Noninvasive diuretic renography is generally preferred. However, optimal interpretation of any of
these test results is uncertain, because both false-positive and false-negative results may be
seen. Nevertheless, the following general recommendations have been made:

Surgical correction should be considered in a patient with pain and positive diuretic
renography findings.
No therapy is necessary in an asymptomatic patient with positive diuretic renography
findings but normal renal function. These patients often are adults and have therefore had the
partial obstruction for many years without apparent damage to the kidney. Hydronephrosis
may first be noted after a radiologic study is performed for some other reason, or, as noted
above, obstruction may be suspected when pain is induced after a period of high fluid intake
leads to a diuresis that exceeds the rate at which urine can flow through the obstructed area.
Similarly, the decreased washout observed on renography occurs only at a urine flow rate
much higher than the patient is likely to achieve on his or her own. Periodic monitoring of renal
function and renal parenchymal size (by ultrasonography) is indicated in these patients to
exclude progressive renal injury.
No therapy is indicated in an asymptomatic patient with negative renography findings.
Long-term follow-up has demonstrated stable renal function in most of these patients.
A perfusion pressure flow study should be performed in a symptomatic patient with
negative or equivocal diuretic renography findings. Some nonrenal cause for the pain is
probably present if the perfusion study is negative. On the other hand, a positive study is
suggestive of obstruction and the need for surgical correction.
A perfusion pressure flow study may also be performed in patients with hydronephrosis
and poor renal function. The diuretic renogram may be falsely negative in this setting, because
the diuretic may not sufficiently raise the urine flow.
In general, approximately 50% of patients with positive diuretic renography findings eventually
require surgery, either for pain or progressive parenchymal loss.[14]

Imaging in children
Detection of antenatal hydronephrosis by ultrasound usually occurs in the second trimester with
a renal pelvic dilation (RPD) cutoff of greater than or equal to 4 mm. Mild hydronephrosis (RPD
of 4-10 mm or Society for Fetal Urology [SFU] grade 1 or 2) can be associated with Down
syndrome or other chromosome anomalies. More severe dilatation increases the risk of renal
and/or urinary tract disorders.
During the ultrasonography, the appearance of the fetal renal system can vary in both healthy
fetuses without hydronephrosis and those with hydronephrosis. Therefore, this diagnosis should
not be based on a single measurement.[15] An increase of maternal hydration can also increase
the RPD in both healthy fetuses and those with hydronephrosis.[16]
If fetal hydronephrosis is detected, the following parameters need to be evaluated using
ultrasonography, as they guide further need for evaluation and are helpful in determining the
cause of hydronephrosis:

Severity of hydronephrosis: The likelihood of a congenital kidney or urinary tract

anomaly increases with the severity of RPD.

Unilateral versus bilateral involvement: Bilateral involvement increases the risk of a

significant renal abnormality and the risk of impaired postnatal renal function.

Ureter: Dilatation of the ureter can be consistent with vesicoureteral reflux (VUR) or
obstructive uropathy distal to the ureteropelvic junction.
Postnatal radiologic studies
Postnatal radiologic evaluation of a newborn with antenatal hydronephrosis begins with an
ultrasonography examination. The timing of ultrasonography and the need for other studies

depend on the severity of postnatal hydronephrosis and whether there is bilateral involvement
or an affected solitary kidney.
Ultrasonography of kidneys and bladder should be performed in the postnatal period on affected
infants. The timing of the study depends on the severity of the antenatal hydronephrosis. In
general, examination should be avoided in the first 2 days after birth because hydronephrosis
may not be detected because of extracellular fluid shifts that underestimate the degree of
hydronephrosis. However, infants with bilateral hydronephrosis and those with a severe
hydronephrotic solitary kidney require urgent evaluation on the first postnatal day because of
the increased likelihood of significant disease and a possible need for early intervention. For
unilateral hydronephrosis without antenatal bladder pathology, performing postnatal sonography
1-4 weeks after birth is recommended.
A voiding cystourethrography (VCUG) is performed to detect VUR and, in boys, to evaluate the
posterior urethra. For this procedure, a urinary catheter is inserted into the bladder and contrast
material is instilled. Fluoroscopic monitoring is performed while the bladder is filling and during
voiding. Infants usually tolerate this procedure well. Although the duration of fluoroscopy is
minimized, the gonads, especially the ovaries, are exposed to radiation.[17]
Diuretic renography is used to diagnose urinary tract obstruction in infants with persistent
hydronephrosis and is usually ordered after a VCUG has demonstrated no vesicoureteral reflux.
[18]
It measures the drainage time from the renal pelvis and assesses total and individual kidney
renal function. The test requires insertion of a bladder catheter to relieve any pressure that can
be transmitted to the ureters and kidneys. Intravenous access is needed for hydration and the
administration of the radioisotope and diuretic. The preferred radioisotope is technetium Tc 99mmercaptoacetyltriglycine (Tc99mMAG3), which is taken up by the renal cortex, filtered across
the glomerular basement membrane to the renal tubules, and excreted into the renal pelvis and
urinary tract.[19]
Diuretic renography includes two phases. First, radioisotope is injected intravenously and renal
parenchymal (cortical) uptake is measured during the first 2-3 minutes. The relative contribution
of each kidney to overall renal function (called the split renal function) is assessed quantitatively
and is useful as a baseline study. Subsequent studies can be compared to assess whether
kidney function remains stable or has deteriorated, suggesting true obstruction.[20]
Second, at peak renal uptake, intravenous furosemide is administered and the excretion of
isotope from the kidney is measured, referred to as the washout curve. This phase indicates the
extent of obstruction, if present. In a healthy kidney, furosemide administration results in a
prompt washout. In a dilated system, if washout occurs rapidly after diuretic administration (<15
min), the system is not obstructed. If washout is delayed beyond 20 minutes, the pattern is
consistent with obstructive uropathy. However, a delayed washout must be interpreted with
caution.[21, 22]
In a series of 39 infants with antenatal unilateral hydronephrosis followed without surgery,
diuretic renography indicated obstruction in 24 patients whose renal function never decreased
and who thus did not have obstruction.[22] These results may be due, in part, to the normally low
neonatal GFR that can be refractory to diuretic therapy. If washout is from 15-20 minutes, the
study is indeterminate.
Gravity-assisted drainage imaging may assist in the assessment of pediatric hydronephrosis.
Unlike customary diuretic renography, in which the patient remains supine, with gravity-assisted
renography a single, static image is obtained after positioning the child in the upright position for

5 minutes to promote additional drainage of tracer from the collecting system. Notable
improvement in drainage with this maneuver suggests that slowness in drainage is not due to
urinary tract obstruction.[23]
Split renal function results are the most useful criteria to evaluate a decrease in renal function.
In patients with unilateral hydronephrosis (which is the most common clinical scenario), if the
normal nonhydronephrotic kidney and hydronephrotic kidney both have equal function,
conservative management without surgery is a safe option. In a cohort of 831 cases of antenatal
hydronephrosis, renal scanning performed in 229 newborns demonstrated that 16% of patients
had a significant decrease in renal function of one kidney, defined as 35% or less differential
renal function.[24] A decrease in differential renal function was associated with severe antenatal
hydronephrosis (ie, renal pelvic diameter >10 mm at 20-24 wk gestation and >16 mm at 33 wk
gestation).
Magnetic resonance urography (MRU) in children is becoming more commonly used in the
diagnosis and management of congenital uropathies such as UPJ obstruction.[25, 26] MRU is
especially useful in the management of obstructed kidneys that have rotation or ascent
anomalies, or are solitary. MRU can more clearly define the anatomy and delineate the proper
surgical approach (ie, retroperitoneal vs transperitoneal). Newer MRU technology may even
define obstruction, eliminating the need for diuretic renal scanning.
The disadvantage of MRU is that the study often requires general anesthesia or heavy
conscious sedation in children. Furthermore, the contrast agent gadolinium can only be used if
renal function is normal (requiring a preprocedure serum creatinine test) because of reports of
irreversible renal fibrosis in patients with renal insufficiency.

Procedures
Antegrade or retrograde pyelography is usually used to relieve, rather than diagnose, urinary
tract obstruction. These tests, however, can also be performed for diagnosis when the history is
highly suggestive (unexplained acute renal failure in a patient with known pelvic malignancy),
even though hydronephrosis may be absent (due to possible ureteral encasement) on
ultrasonography and CT scanning.[12]

Medical Care
The role of medical treatment of hydronephrosis and hydroureter in adults is limited to pain
control and treatment or prevention of infection. Most conditions require either minimally
invasive or open surgical treatment. Two notable exceptions are (1) oral alkalinization therapy
for uric acid stones and (2) steroid therapy for retroperitoneal fibrosis.
The management approach to infants with antenatal hydronephrosis is based on the
confirmation of persistent postnatal hydronephrosis and the following two predictive factors:

Bilateral involvement
Severe hydronephrosis: Fetuses with a renal pelvic diameter greater than 15 mm during
the third trimester are at the greatest risk for significant renal disease
Bilateral hydronephrosis
Infants with severe bilateral antenatal hydronephrosis and/or bladder distension are at
increased likelihood of having significant disease. These infants and those with a severe

hydronephrotic solitary kidney should be evaluated initially by ultrasonography on the first

postnatal day. Bilateral hydronephrosis suggests an obstructive process at the level of or distal
to the bladder, such as ureterocele or posterior urethral valves (PUV) in a male infant, which can
be associated with impaired renal function and ongoing renal injury.
If postnatal ultrasonography demonstrates persistent hydronephrosis, voiding
cystourethrography (VCUG) should be performed. In male infants, the posterior urethra should
be fully evaluated to detect possible PUVs.
Infants with mild or moderate hydronephrosis can be evaluated after 7 days of life.

Severe unilateral hydronephrosis

In newborns with severe antenatal unilateral hydronephrosis (renal pelvic diameter >15 mm in
the third trimester), ultrasonography should be performed after the infant returns to birth weight
(after age 48 h and within the first 2 wk of life).

Moderate and mild unilateral hydronephrosis

In newborns with less severe antenatal unilateral hydronephrosis (renal pelvic diameter < 15
mm during third trimester), ultrasonography can be performed after age 7 days to see whether
the hydronephrosis has persisted postnatally.
Moderate hydronephrosis resolves by age 18 months in most cases. This was illustrated by a
prospective study of 282 infants (age 2 mo) with renal pelvic diameters between 10 and 15 mm,
which resolved in 94% of patients by age 12-14 months (resolution was defined as renal pelvic
diameter 5 mm on two consecutive ultrasounds). Of the 18 patients with persistent
hydronephrosis, 14 had ureteropelvic junction (UPJ) obstruction and 4 had vesicoureteral reflux
(VUR).[27]

Antibiotic prophylaxis
Higher rates of urinary tract infections have been reported in children with prenatally diagnosed
hydronephrosis compared with the general pediatric population.[28, 29] The risk of infection rises if
there is an underlying urologic abnormality, such as VUR or obstructive uropathy, and is greater
in girls compared with boys.[30]
As a result, in infants with severe hydronephrosis who are at greater risk for an underlying
urologic abnormality, antibiotic prophylaxis is started after delivery until the diagnosis of VUR or
obstructive uropathy is excluded.
Antibiotic prophylaxis in children with mild or moderate hydronephrosis confirmed postnatally
has not been studied prospectively. In one retrospective study of 1514 with mild persistent
hydronephrosis, the use of prophylactic antibiotics reduced the risk of febrile urinary tract
infection in patients who had VUR.[31] Until further prospective studies are conducted, antibiotic
prophylaxis should be considered until VCUG has been performed and either the diagnosis of
VUR has been made or eliminated.
Antibiotic prophylaxis is not needed in infants with normal postnatal ultrasonography findings.[32]
Three recent retrospective studies have considered the role of antibiotic prophylaxis in infants
with hydronephrosis. Zareba et al analyzed the risk factors for urinary tract infection (UTI) in 376
infants with prenatal hydronephrosis and reported that infants with high-grade hydronephrosis,

girls, and uncircumcised boys were at highest risk for UTI. Antibiotic prophylaxis did not
decrease the risk in any of the groups studied.[33]
In a systematic review that included 3876 newborns with antenatal hydronephrosis, Braga et al
found that infants with high-grade hydronephrosis receiving continuous antibiotic prophylaxis
(CAP) had significantly lower UTI rates than those who did not receive an antibiotic regimen
(14.6% vs 28.9%). However, the rates for infants with low-grade hydronephrosis were similar
(2.2% vs. 2.8%). The researchers cautioned that the level of evidence of available data was
moderate to low.[34]
Herz et al reviewed the records of 278 children maintained on CAP and 127 who were not and
compared individual characteristics to determine risk factors for UTI. The presence of ureteral
dilation, high-grade VUR, and ureterovesical junction obstruction were independent risk factors
for development of UTI. CAP had a significant role in reducing UTI in children with the risk
factors but was unnecessary otherwise.[35]

Surgical Care
The specific treatment of a patient with hydronephrosis and hydroureter depends, of course, on
the etiology of the process. Several factors help determine the urgency with which treatment
should be initiated. In general, any signs of infection within the obstructed system warrant
urgent intervention because infection with hydronephrosis may progress rapidly to sepsis. A
mildly elevated white blood cell count is often observed in patients with stones but does not
necessarily mandate immediate action in the absence of other signs or symptoms of systemic
infection. However, even a low-grade fever in a diabetic or immunosuppressed patient (ie, on
steroid therapy) requires immediate treatment.
The potential for loss of renal function also adds to the urgency (eg, hydronephrosis or
hydroureter bilaterally or in a solitary kidney). Finally, patient symptoms help determine the
urgency with which treatment is initiated. For example, refractory pain in a patient with an
obstructing ureteral calculus necessitates intervention, as does intractable nausea and vomiting.
Urethral catheterization is important to help rule out a lower tract cause for hydronephrosis and
hydroureter. Difficulty in placing a Foley catheter may suggest urethral stricture or bladder neck
contracture.
Urologists commonly use ureteral stent placement in cases of intrinsic and extrinsic causes of
hydronephrosis. The procedure is usually performed in conjunction with cystoscopy and
retrograde pyelography. Stents can bypass an obstruction and dilate the ureter for subsequent
endoscopic treatment.
Urologists or interventional radiologists can place a percutaneous nephrostomy tube if ureteral
stenting is not possible. Usually, ultrasonography is used first to locate the dilated collecting
system. Using the Seldinger technique, a tube ranging from 8-12F can be placed.
Nephrostomies are typically placed when a retrograde stent cannot be passed because of
anatomic changes in the bladder or high-grade obstruction in the ureter. Because this procedure
can be performed under local anesthesia, patients who are too hemodynamically unstable for
general anesthesia may undergo percutaneous nephrostomy tube placement. In addition,
nephrostomy tube placement may be performed with minimal use of radiation and may be
useful in pregnant patients.
Advances in endoscopic and percutaneous instrumentation have decreased the role of open or
laparoscopic surgery for hydronephrosis. Certain causes of hydronephrosis, mostly extrinsic,

still require treatment with open surgery. Examples include retroperitoneal fibrosis,
retroperitoneal tumors, and aortic aneurysms. Some stones that cannot be treated
endoscopically or with extracorporeal shockwave lithotripsy require open removal. Although
endoscopic management does play a role in low-grade low-stage ureteral tumors, these lesions
also usually require open or laparoscopic surgical management.
Urine should be collected from the kidney when obstruction is relieved to allow identification and
targeted treatment of any infection that may be present.

Fetal surgery
Although several prospective and retrospective studies have examined antenatal surgery in
fetuses with sonographic findings consistent with lower urinary tract obstruction, no good
evidence supports that this intervention improves renal outcome.[36] Although these procedures
may increase the amount of amniotic fluid, thus potentially improving lung development and
survival rate, the rate of chronic renal disease is high in survivors, necessitating renal
replacement therapy in almost two thirds of the cases.
The benefit of vesicoamniotic shunting (VAS) proved inconclusive in the Percutaneous
vesicoamniotic shunting in Lower Urinary Tract Obstruction (PLUTO) trial, which compared VAS
with conservative nonsurgical management in 31 singleton fetuses younger than 28 weeks
gestation with isolated bladder outflow obstruction. Although survival to 28 days and 1 year
appeared to be higher with VAS than with conservative management, the PLUTO investigators
could not prove benefit beyond reasonable doubt, and VAS was substantially more costly.[37]
Newborns in the PLUTO trial had a very low chance of surviving with normal renal function,
regardless of whether they underwent VAS. Short-term and long-term morbidity in both trial
groups was substantial, and complications of VAS resulted in pregnancy loss in some cases.[37]

Consultations
Refer the patient to a urologist whenever hydronephrosis or hydroureter is newly diagnosed.
Further consultations may be sought by the urologist, depending on the circumstances. For
example, a nephrologist's input would be useful in cases of severe pathological postobstructive
diuresis. In addition, an interventional radiologist would be needed for nephrostomy tube
placement if urgent decompression is needed and ureteral stent placement is not possible.
Patients with antenatal and postnatal hydronephrosis should be referred to a pediatric urologist
for evaluation and management.