Hydronephrosis by Dr.K.AmrithaAnilkumar

HYDRONEPHROSIS (HN)
DEFINITION
It is an aseptic dilatation of pelvicalyceal system due to partial or intermittent obstruction to the outflow of urine.
AETIOLOGY
unilateral
bilateral.

1. e n love da Homoeopathy HYDRONEPHROSIS

2. HYDRONEPHROSIS

3. HYDRONEPHROSIS (HN) DEFINITION It is an aseptic dilatation of pelvicalyceal system due to partial or intermittent obstruction to the outflow of urine. AETIOLOGY unilateral bilateral.

4. UNILATERAL A.Extra mural: Aberrant renal vessels (vein or artery). It is common on left side Compression by growth (carcinoma cervix, carcinoma rectum). Retroperitoneal fibrosis. Retrocaval ureter B. Intramural: Congenital PUJ obstruction. Ureterocele . Neoplasm of ureter Narrow ureteric orifice Stricture ureter following removal of stone, pelvic surgeries or tuberculosis of ureter. Intraluminal: Stone in the renal pelvis or ureter Sloughed papilla in papillary necrosis .

5. BILATERAL Congenital Congenital stricture of external urethral meatus, pin-hole meatus. Congenital posterior urethral valve. Congenital PUJ is the most common cause of HN. present on one side is earlier than the other side. Aberrant renal artery or vein in the lower pole of kidney can compress the PUJ causing HN. Renal angiogram confirms the diagnosis In pregnancy dilatation of ureters and both pelvis occur due to atony of ureteric musculature by progesterone. It starts as early as in the first few weeks of pregnancy and lasts until few weeks after delivery. Involution occurs 2–12 weeks after delivery

6. B. Acquired: BPH. Carcinoma prostate. Postoperative bladder neck scarring. Inflammatory/traumatic urethral stricture. Phimosis. Carcinoma cervix. Bladder carcinoma PATHOLOGY 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 leading to compromised secretory function .

7. ↓ Parenchymal thickness of less than 2 mm is unlikely to function. ↓ In bilateral cases such patients will go for renal failure CLINICAL FEATURES A. In unilateral cases: Congenital PUJ obstruction and calculus are the most common causes. M : F : : 2 : 1. Right side kidney is affected more commonly. Dull aching loin pain with dragging sensation or heaviness. Mass in the loin which is smooth, mobile, ballotable , moves with respiration with dullness in renal angle and a band of colonic resonance in front. Attacks of acute renal colic

8. Dietl’s crisis—after an acute attack of renal colic, swelling in the loin is seen which disappears after sometime following passage of large volume of urine. Dysuria, haematuria, if infected fever and tenderness in renal angle. Occasionally hypertension. B. In bilateral cases: From lower urinary tract obstruction Loin pain Features of bladder outlet obstruction—frequency Hesitancy poor stream Kidneys are often not palpable if renal failure develops early From bilateral upper urinary tract obstruction. mass in the loin attacks of renal colic In bilateral cases, when it is severe, features of renal failure like oliguria, oedema, hiccough may be present

9. COMPLICATION 1. Pyonephrosis . 2. Perinephric abscess. 3. Renal failure in bilateral cases. INVESTIGATION Blood urea and serum creatinine. Urine for microscopy. To find out the function of diseased as well as opposite kidney. Normal calyx is cup shaped. Ultrasound abdomen: Investigation of choice. Type of pelvis thickness of parenchyma, site of obstruction and cause of obstruction, e.g. stones, can be made out. It gets flattened and later club shaped which even tually becomes broadened in hydronephrosis .

10. CT scan is diagnostic Isotope renography is also useful to study the function of the kidney before and after the surgical treatment also to see the efficacy of surgery as far as function is considered—DTPA scan. TREATMENT Always conservative surgeries which are aimed at con- serving the kidneys are done. Nephrectomy is not done unless indicated. The cause is treated : Stone congenital anomaly aberrant renal vessels stricture urethra (dilatation, urethrotomy , urethroplasty ) phimosis (circumcision ); BPH ( TURP) posterior urethral valve ( cystoscopic fulguration of valve).

11. 2. Anderson- Hyne’s operation (Dismembered pyelo plasty ): In congenital PUJ obstruction the spasmodic segment and redundant pelvis are excised 3. Davis T-tube ureterostomy: Placement of T-tube in the ureter by making longitudinal incision. 4. Non-dismembered pyeloplasties : Here PUJ is not transected . Reconstruction is done without PUJ transection by different methods, e.g. Foley’s Y-V plasty .

12. 5. In bilateral HN, without renal failure, kidney which is functioning better should be operated first. Three months later, otherside kidney is dealt with. 6. In bilateral HN with renal failure, bilateral nephrostomy and haemodialysis support is required initially REFERENCE SRB's Manual of Surgery by Sriram Bhat M 2. A Manual on Clinical Surgery by Das 3. A C oncise textbook of Surgery by Das

13. A Special Thanks To A Very Special Doctor