Gandhi HUN.pptx

Hun

1. HYDRONEPHROSIS Dr.S.S.Gandhi 1 st year PG Dept. Of General Surgery

2. CONTENTS General Investigations Special investigations Treatment Complications 2

3. EVALUATION Depending upon the presentation and whether there is acute onset of symptoms, Physical examination - tenderness in the flank or where the kidneys are located. The bladder - distended when the abdomen is examined. PR for males shows the size of the prostate. 5

4. Pelvic examination in females may be performed to evaluate the uterus and ovaries .

5. Urin e an alysis to look for blood, infection or abnormal cells Complete blood count (CBC) may reveal anemia or potential infection Electrolyte analysis may be helpful in chronic hydronephrosis since the kidneys are responsible for maintaining and balancing their concentrations in the blood stream. 5 1

6. X RAY KUB KUB X-rays (an X-ray that shows the kidney, ureter, and bladder) are used to classify a kidney stone as radiodense or radiolucent . KUB X-rays are used to determine if the stone is able to migrate down the ureter into the bladder. 52

7. NORMAL KIDNEY H Y D RO N E P HR O SI S 8

8. I V P IVP : Dilatation of renal pelvis decreasing concavity and then flattening of minor calyces with dilatation of major calyces a portion of pelvis becomes more dependant part below the level of PVJ 53

9. NORMAL INTRAVENOUS PYELOGRAM (IVP) 19

10. Special investigations Excretory urography Retrograde urography Ultrasound 5 4

11. Excretory Urogram

12. Retrograde Pyelogram (RP) Retrograde pyelogram is used to determine whether stone or other thing that is obstructing the urinary pathway. This is used in Some people with contra indictions for IVP in which dye is introduced into the veins .

13. CT scan of the abdomen can b e done to evaluate the kidney anatomy and it will help in mak ing t he diagnosis of hydronephrosis . It also may allow look for the underlying cause including kidney stones or structures that are compressing the urinary collecting system. CT scan 16

14. PRINCIPLES OF TREATMENT 17 In adults, the aims of treatment are to: R emove the build-up of urine and relieve t th e pressure on kidney s. Pr event permanent kidney damage . Tr eat the underlying cause

15. Most people with hydronephrosis should have catheterisation to drain the urine from their kidneys. Depending on the underlying cause, medication or surgery may be needed afterwards to correct the problem. If the condition is severe or causing problems such as a urinary tract infection (UTI), it may be treated soon after it is diagnosed.

16. The first stage in treating hydronephrosis is to drain the urine out of the kidneys. This will help ease pain and prevent any further damage to kidneys. A thin tube called a catheter may be inserted into your bladder through urethra or through spc . 19

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18. TREATMENT GOAL • • • • The goal of treatment for hydronephrosis is to restart the free flow of urine from the kidney and decrease the swelling and pressure that builds up and decreases kidney function. The initial care for the patient is aimed at minimizing pain and preventing urinary tract infections. The timing of the procedure depends upon the :underlying cause of hydronephrosis and hydroureter and the associated medical conditions that may be present. 6

19. For example, patients with a kidney stone may be allowed 1-2 weeks to pass the stone with only supportive pain control if urine flow is not completely blocked by the stone. If, however, the patient develops an infection or if they only have one kidney, surgical intervention may be done emergently. To remove the stone.

20. For patients with urinary retention and an enlarged bladder as a cause of hydronephrosis, bladder catheterization may be all that is needed for initial treatment. When a stent cannot be placed, an alternative is inserting a percutaneous nephrostomy tube. A urologist or interventional radiologist uses fluoroscopy to insert a tube through the flank directly into the kidney to allow urine to drain. 6 1

21. Per cutaneous Nephrostomy :

22. Shock wave lithotripsy(SWL ) Shock wave lithotripsy(SWL or extracorporeal shock wave lithotripsy) is the most common treatment for kidney stones . Shock waves from outside the body are targeted at a kidney stone causing the stone to fragment into tiny pieces that are able to be passed out of the urinary tract in the urine. 62

23. For patients with ureteral strictures or stones that are difficult to remove, stent may be placed into the ureter that bypasses the obstruction and allows urine to flow from the kidney . 63

24. Using a fiber optic scope inserted through the urethra into the bladder, can visualize where the ureter enters and can thread the stent through the ureter into the kidney pelvis bypassing any obstruction .

25. Treating hydronephrosis in babies 28 Most babies diagnosed with hydronephrosis before they're born (antenatal hydronephrosis) won't need any treatment because the condition will improve before they're born or within a few months of their birth. Investgiations are done for babies like: A n ultrasound scan M icturating cystourethrogram (MCUG) – where a thin tube is used to pass a special type of liquid that shows up clearly on X-rays into thebaby's bladder while a series of X-rays are taken .

26. Dimercaptosuccinic acid (DMSA) scan or MAG-3 scan – where they are injected with a substance that shows up on a special device called a gamma camera; the camera is then used to take pictures of child's kidneys In most children, hydronephrosis will get better as they get older. If hydronephrosis doesn't get better by itself, your child may need to keep taking antibiotics. Occasionally, surgery may be recommended to treat the underlying cause of the condition

27. INDICATIONS OF OPERATIONS : Increasing renal pain increasing hydronephrosis When hydronephrosis is complicated by infection/parenchymal damage. PROCEDURES : Nephrectomy Plastic operations Endoscopic pyelolysis / endoscopic pyelotomy Endoscopic ballon dilatation 30

28. Principles of pyeloplasty 31 To reduce the size of the renal pelvis Excision of the PUJ The ureter is attached to the most dependent part of the pelvis

29. 6 7 E xtraperitoneal flank approach, bed of the 12t h rib

30. Treatment Secondary hydronephrosis: treatment of the cause Primary hydronephrosis: Pyeloplasty: Anderson- Hynes Culp Foley Nephrectomy 6 9

31. PROCEDURES FOR PRIMARY HYDRONEPHROSIS 7

32. Anderson- Hynes Pyeloplasty : In this procedure , upper one third of ureter and Renal pelvis are mobilised Anastamosis is made between ureteric end and kidney A Nephrostomy tube was placed in order to protect the anastamosis

33. S titches are placed on the renal pelvis superior to the obstruction and the lateral aspect of the proximal ureter below the level of the obstruction. b The ureteropelvic junction tissue is then excised and an anastomosis is created with fine interrupted or running absorption sutures. c The sutures are placed in a watertight manner over an internal ureteral stent, which remains in situ . 72

34. 7 3 A spiral incision is made in the enlarged renal p elvis and extended an equal distance into the ureter. b | The tissue flap is turned down and stitched into the adjacent ureter. c | The flap is closed with fine interrupted or running absorption sutures.

35. 7 4 a | The ureter is pulled with a stitch while a Y-shaped incision is made in the renal pelvis and ureter. b | A V-shaped flap is opened in the ureteropelvic junction tissue. c | The V-shaped flap is sutured to the apex of the ureteral incision with fine interrupted or running absorption sutures.

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38. COMPLICATIONS Development of a urinary tract infection (UTI). When the UTI is associated with a high fever, a kidney infection is (pyelonephritis) is suspected. This is caused by bacteria spreading from the bladder to the kidney and invading the kidney tissue. If pyelonephritis is severe or not treated in a timely manner, or if it affects both kidneys, complications such as permanent kidney damage (kidney scarring) can lead to problems such as high blood pressure and sometimes kidney failure . 77

39. R O B O T- A S S I ST E D PYELOPLASTY A robot-assisted pyeloplasty is a minimally invasive laparoscopic procedure. With the use of a tiny camera, surgeons operate using very thin instruments inserted into three or four small incisions. Robot-assisted pyeloplasty removes an obstructed section of the ureter and reattaches the healthy portion to the kidney's drainage system. 78

40. Thank you