HYDRONEPHROSIS

R.EUREKA
MSC(N) II yr
HYDRONEPHROSIS
DEFINITION

Hydronephrosis refers to dilatation of the

renal pelvis and calyces, with accompanying
atrophy of the parenchyma, caused by partial
& intermittent obstruction to the outflow of
urine .

Hydronephrosis is distention (dilation ) of the

kidney with urine, caused by backward
pressure on the kidney when the flow of urine
is obstructed.
INCIDENCE

• Common in males
• Frequently affects left kidney
HYDRONEPHROSIS OBSTRUCTION
LEVELS

• Renal pelvis
• Pelviureteric junction
• Ureter
• Bladder
• Urethra
TYPES

UNILATERAL
Caused by obstruction at the level of
the ureter, pelviureteric junction or
renal pelvis.
BILATERAL
Caused by obstruction at the level of
the bladder or urethra
PRIMARY HYDRONEPHROSIS
SECONDARY HYDRONEPHROSIS
TYPES OF OBSTRUCTION
INTRAMURAL
EXTRINSIC -Transitional cell cancer
-Trauma -Fibrosis
-Tumour -Inflammation
-Inflammation -Infection
-Infection
-Haemorrhage
-Fibrosis

INTRALUMINAL
-Calculus
-Blood clot
-Renal papilla
 OBSTRUCTIONS OF THE URINARY
TRACT
Types and locations

Congenital pelviureteric
junction obstruction

Retroperitoneal fibrosis,
Calculi tumours, haemorrhage

Cancer of Functional:
-Ovary vesicoureteric reflux
-Cervix Neurogenic bladder
-Uterus

Prostatic hypertrophy Bladder cancer

or cancer
ETIOLOGY

1.PRIMARY HYDRONEPROSIS
• Intrinsic stricture
• High insertion of the ureter
• PUJ
• Nephroptosis
• Extrisic compression
• Renal pelvic stone or tumor
2.SECONDARY HYDRONEPHROSIS
• Vesicoureteral reflux
• Obstruction distal to the ureteropelvic junction:
stone, tumor, extrinsic ureteral compression
• bladder outflow obstruction: BPH
• Urethral obstruction
• Pregnancy
• Ureterocele
• Cancers of bladder, cervix, uterus, prostate or
other pelvic organs
• Abnormal contraction of the bladder: birth defects,
spinal cord injury, nerve injury
• Disorders of muscles or nerves in the ureter or
THE CAUSES OF
HYDRONEPHROSIS
PATHOPHYSIOLOGY

Anatomic and functional processes

interrupts the flow of urine

rise in ureteral pressure

stretching and dilation

; pressures continue to rise

decline in renal blood flow and GFR

renal impairment
HYDRONEPHROSIS ( CUT
SURFACE)
GRADING OF SEVERITY OF
HYDRONEPHROSIS
Grade Central Renal Renal
Complex Parenchymal
Thickness
0 Intact Normal
1 Slight splitting Normal
2 Evident splitting Normal
3 Wide splitting Normal
4 Further dilatation Thin
CLINICAL FEATURES
• Asymptomatic (in some cases)
• Pain in the renal area
• Hematuria
• Urinary infection
• Dysuria
• Calculi
• Azotemia
• Unexplained vague GI symptoms (nausea, vomiting)
• Pus in the urine
• Fever
• Discomfort in the area of bladder
• Some large hydronephrosis can be palpable
DIAGNOSTIC FINDINGS
History collection
Physical examination
DIAGNOSIS BEFORE BIRTH
Routine prenatal ultrasound – Reveal
earliest signs of obstruction
Fetal kidney function by measuring the
fetus, kidney & amniotic fluid levels
Hydronephrosis
Hydronephrosis Intravenous
pyelogram (IVP)
Antegrade
pyelography

Left PUJ stenosis is

considered
DIAGNOSIS AFTER BIRTH
Voiding cystourethrogram – detect
backwash of urine into the ureters and
kidneys & any blockages in the urethra
Renal ultrasound – size & shape of kidneys
& any obstruction or anomalies
IVP
KUB X-ray
Renal scan – severity of obstruction
Cystoscopy
Reterograde pyelogram – distal obstruction
CT Scan
Endoscopy – to examine the urinary
tract
Blood & Urine investigation : Serum
creatinine, BUN, Urine routine &
culture
TREATMENT
• Aims to relieve the symptoms
• Antibiotic therapy to treat infections
• Uretheral stent
• Nephrostomy tube
• Pyeloplasty for PUJ obstruction
• Lithotripsy or Endoscopic surgery – stones
• Nephrectomy – tumor & non functioning
kidney
• Relief of lower tract obstruction : Catheter
drainage, Urinary diversion, Indwelling pigtail
uretheral catheter
SURGICAL MANAGEMENT
INDICATION
Presence of symptoms associated
with the obstruction
Impairment of overall renal function
Progressive impairment of ipsilateral
function
Development of infection or stones
Hypertension
PYELOPLASTY

• Open pyeloplasty
 Dismembered pyeloplasty / Anderson -
hynes operation
 Foley Y-V pyeloplasty
 Culp pyeloplasty
 Spiral flap
• Laparoscopic pyeloplasty
• Robotic pyeloplasty
TREATMENT FOR UPJ
PYELOPLASTY- plastic refashioning
operation
DISMEMBERED PYELOPLASTY-
[ANDERSON-HYNES OPERATION]
The top of the ureter is cut from the renal
pelvis.The exit aperature in the renal pelvis is
opened & made larger.The ureter is opened
down its length.A large anastomosis is then
possible.If extra blood vessels is present in
the lower pole, then this method is very
suitable to relocate the ureter on the other
side of the vessels.Left flank muscle artery
incision is made.Sucess rate is 94-98%.
DISMEMBERED PYELOPLASTY-
[ANDERSON-HYNES OPERATION]
FOLEY Y-V PYELOPLASTY
• Y shaped incision is made in the renal pelvis
& ureter crossing the PUJ.
• The tail of Y incision extends down the ureter.
• The flap created in the renal pelvis is
advanced down the ureter
• It is then sutured as V
• Good for 1 – 2 cm obstruction
• Suitable for high inserting ureter and small
pelvis.
• Facilitates better drainage of urine from the
renal pelvis.
Foley Y-V-Plasty
CULP PYELOPLASTY

Complicated operation
Incision is made in the renal pelvis to
form a flap
One side of the flap incision is
extended down the PUJ
The flap of renal pelvis is rotated to
180 degree & sutured into the upper
ureter
SPIRAL FLAP

– Good for long obstructions

– Length of flap is limited only by
size of pelvis
– Keep length: width at 3:1)
– Good when UPJ angle > 90
Spiral Flap
LAPAROSCOPIC PYELOPLASTY

 Provides a key hole operation

 Dismembered pyeloplasty is most
common procedure performed
 Up to 94% success rate
ROBOTIC PYELOPLASTY

• Robot - assisted laparoscopic

dismembered pyeloplasty.
– Minimal blood loss
– Short hospitalization
– success rate of 94%.
CORRECTION OF PELVI-
URETERIC STENOSIS
COMPLICATIONS OF
HYDRONEPHROSIS

• UTI
• Renal impairment
• Renal calculi
 PROGNOSIS OF
HYDRONEPHROSIS
Depends on the cause, site, duration,
and degree of kidney damage .
NURSING MANAGEMENT

• Bed rest
• Monitor vital signs
• Maintain IO chart
• Maintain hygiene
• Watch signs of urinary tract
obstruction
• Prenatal ultrasound to find earlier
signs of obstruction
• Support to family members
Thank you