Hydronephrosis.pptx

Lecture notes for medial students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also . Good for self study also. Display blank slide> Think what you already know about this > Read next slide . See notes for bibliography.

2. Hydronephrosis .

3. Hydronephrosis . Hydronephrosis is the term to describe dilation of the renal pelvis and calyces with urine associated with progressive atrophy of the kidney due to obstruction to the outflow of urine .

4. Types of Obstruction

5. Types of Obstruction SUDDEN INSIDIOUS, PARTIAL or COMPLETE, UNILATERAL or BILATERAL;

6. Epidemiology

7. Epidemiology Autopsy 3.1%. 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.

8. Epidemiology Autopsy studies also indicate that hydronephrosis is present in 2-2.5% of children. 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.

9. Types of Lesions

10. Types of Lesions It can be caused by lesions that are Intrinsic to the urinary tract or Extrinsic lesions that compress the ureter.

11. Obstructive lesions of the urinary tract

12. Etiology

13. Etiology  1.     Congenital anomalies 2.    Urinary calculi    3.    Benign prostatic hypertrophy    4.    Tumors 5. Inflammation    6.    Sloughed papillae or blood clots    7.    Pregnancy    8.    Uterine prolapse and cystocele 9.    Functional disorders

14. Etiology Anatomic abnormalities (including urethral valves or stricture, and stenosis at the ureterovesical or ureteropelvic junction) account for the majority of cases in children. Calculi are most common in young adults, Prostatic hypertrophy or carcinoma, retroperitoneal or pelvic neoplasms , and calculi are the primary causes in older patients.

15. Physiological

16. Physiological Hydronephrosis or hydroureter is a normal finding in pregnant women. progesterone effects and mechanical compression of the ureters at the pelvic brim. More prominent on the right These changes can be visualized on ultrasound examination by the second trimester, and they may not resolve until 6-12 weeks post partum.

17. Acute Vs. Chronic

18. Acute Vs. Chronic We may consider acute as hydronephrosis that, when corrected, allows full recovery of renal function. 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.

19. When the obstruction is SUDDEN and COMPLETE , GLOMERULAR FILTRATION IS REDUCED. It leads to MILD DILATION OF THE PELVIS and CALYCES and sometimes to ATROPHY OF THE RENAL PARENCHYMA.

20. When the obstruction is SUBTOTAL or INTERMITTENT , GLOMERULAR FILTRATION IS NOT SUPPRESSED, and PROGRESSIVE DILATION ENSUES

21. The kidney may be slightly to massively ENLARGED, depending on the degree and the duration of the obstruction .

22. In far-advanced cases the kidney may become transformed into A THIN-WALLED CYSTIC STRUCTURE having a diameter of up to 15 to 20 cm with striking PARENCHYMAL ATROPHY, TOTAL OBLITERATION OF THE PYRAMIDS, and THINNING OF THE CORTEX.

23. Pathology  

24. Pathology  Compression of the papillae, thinning of the parenchyma around the calyces, and coalescence of the septa between calyces. Dilation of the tubular lumen and flattening of the tubular epithelium. Fibrotic changes and increased collagen deposition are observed in the peritubular interstitium .

25. Complications

26. Complications Urinary stasis may result in Infection Renal scarring Calculus formation Sepsis Renal failure Hypertension

27. Clinical Features

28. Clinical Features Acute obstruction – PAIN due to distention of the collecting system or renal capsule. 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.

29. Clinical Features II Unilateral complete or partial hyd ronephrosis may remain SILENT FOR LONG PERIODS , since the unaffected kidney can maintain adequate renal function. Sometimes its existence first becomes apparent in the course of USG or INTRAVENOUS PYELOGRAPHY.

30. Clinical Features III. In bilateral partial obstruction the earliest manifestation is inability to concentrate the urine, reflected by POLYURIA AND NOCTURIA. .

31. Clinical Features Other symptoms Anuria Hematuria Fever Antenatal USG.

32. Clinical Features:Physical Exam 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

33. Diagnostic Studies

34. Diagnostic Studies Laboratory Tests Imaging X-ray + Contrast studies. USG CT MRI Nuclear Scan Other Tests

35. Laboratory Studies

36. Laboratory Studies Urinalysis- Pyuria suggests the presence of infection. Microscopic hematuria may indicate the presence of a stone or tumor . CBC leukocytosis , which may indicate acute infection. Serum Creatinine levels Hypercalemia can be a life-threatening condition.

37. Imaging studies

38. Imaging studies Renal ultrasonography is the test of choice Intravenous Urography CT Indications : Ultrasonography results are equivocal The kidneys cannot be well visualized The cause of the obstruction cannot be identified.

39. Imaging studies Diuretic Renography with technetium Tc 99m-mercaptoacetyltriglycine (Tc99mMAG3), A perfusion pressure flow study  Diffusion-weighted magnetic resonance imaging (MRI) Antegrade or retrograde pyelography is usually used to relieve, rather than diagnose, urinary tract obstruction.

40. Imaging in children

41. 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. Postnatal ultrasound.  A voiding cystourethrography (VCUG) is performed to detect VUR and, in boys, to evaluate the posterior urethra.  Diuretic renography Magnetic resonance urography (MRU)

42. Differential Diagnosis

43. Differential Diagnosis Other problems to consider in the differential diagnosis include the following: Peripelvic cyst Congenital megacalices Calyceal diverticula Capacious extrarenal pelvis<> High urine flow Pyelonephritis

44. Non Operative Therapy  

45. Non Operative Therapy  Pain control Treatment or prevention of infection Oral alkalinization therapy for uric acid stones and Steroid therapy for retroperitoneal fibrosis.

46. Minimally invasive Therapy

47. Minimally invasive Therapy Extracorporeal shockwave lithotripsy Urethral Catheterisation . SPC Ureteral catheterisation +- stent Nephrostomy Post. Urethral Valve fulguration.

48. Operative Therapy:Indications

49. Operative Therapy:Indications Any signs of infection Fever, leucocytosis The potential for loss of renal function also adds to the urgency ( eg , hydronephrosis or hydroureter bilaterally or in a solitary kidney). Refractory pain in a patient with an obstructing ureteral calculus necessitates intervention, Intractable nausea and vomiting.

50. Operative Therapy Mostly extrinsic Retroperitoneal fibrosis, Retroperitoneal tumors Aortic aneurysms. Some stones that cannot be treated endoscopically or with extracorporeal shockwave lithotripsy Ureteral tumors ,

51. On The Horizon Fetal Surgery VAS – VesicoAmniotic Shunting

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