Hydronephrosis

Definition
An aseptic dilatation of the renal
pelvis and calyces due to partial or
intermittent obstruction to the
outflow of urine.
Etiology
It can be unilateral or bilateral
Unilateral
Hydronephrosis
Extramural Causes-
Obstruction by renal vessels (vein or
artery)
Compression by growth (CA cervix
or carcinoma rectum)
Retroperitoneal fibrosis


Intramural causes-
Congenital pelviuretric junction
obstruction
Ureterocele
Neoplasm of ureter
Narrow ureteric orifice
Stricture ureter following removal of
stone, pelvic surgeries or tuberculosis of
ureter



Intraluminal causes-
Stone in the renal pevis or ureter
Sloughed papilla in papillary
necrosis

Congenital causes
Congenital stricture of external
urethral meatus or pin-hole meatus
Congenital posterior urethral valve
Bilateral Hydronephrosis
Acquired causes
BPH
Carcinoma prostate
Bladder carcinoma
Inflammatory/traumatic urethral
stricture
Phimosis
Postoperative bladder neck scarring
Carcinoma cervix

Obstructive lesions of the urinary
tract
Pathophysiology
Anatomic and functional processes
interrupts the flow of urine
There is raise in ureteral pressure causing
stretching and dilatation; if pressure
continue to raise, it leads to decline in renal
blood flow and GFR
When significant obstruction is persistent,
it affects renal tissue and results in varying
degrees of cystic dysplasia and renal
impairment
Obstruction can be sudden or insidious,
partial or complete, unilateral or bilateral


May occur at any level from urethra to the
renal pelvis


Obstruction increases succeptibility to
infection and to stone formation


Unrelieved obstruction almost always
leads to permanent renal atrophy
Initially pressure burden is taken up by
the pelvis ,later calyces and renal
parenchyma

Gradually parenchyma thins out due to
destruction and it dilates

Eventually secretory function gets
compromised

Parenchymal thickness of less thn 2mm
is unlikely to function.in bilateral cases
such patients go for renal failure


The high pressure in the pelvis is transmitted back
through the collecting ducts into the cortex, causing
renal atrophy

It also compresses the renal vasculature of the
medulla, causing a diminution in inner medullary blood
flow
The medullary defects are reversible initially but lead
to medullary functional disturbances

The initial functional alterations caused by obstruction
are largely tubular, manifested primarily by impaired
concentrating ability

Only later the GFR begins to fall

Obstruction also triggers an interstitial inflammatory
reaction leading eventually to interstitial fibrosis

The kidney may be slightly to massively
enlarged, depending upon the degree and
duration of the obstruction
Earlier features are dilatation of renal pelvis
and the calyces with significant interstitial
inflammation
In chronic cases the picture is one of cortical
tubular atrophy with marked diffuse interstitial
fibrosis
Progressive blunting of the apices of pyramid
occurs and eventually becomes cupped
In advanced cases,kidney may become cystic
structure having a diameter of 15-20cm
Stages of
Hydronephrosis
cup
flat
club
broadened
types of renal pelvis
Intrarenal

extrarenal
Extrarenal pelvis refers to the presence of the
renal pelvis outside the confines of the renal
hilum. It is a normal variant that is found in ~10%
of the population .


The renal pelvis is formed by all the major
calyces. An extarenal pelvis usually appears
dilated giving a false indication of an obstructive
pathology. Subsequent investigation with CT,
usually clarifies the false interpretation on
ultrasound.