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Bilateral Hydronephrosis and Ureterectasis to the Ureterovesical Junction

Jennifer Pittman
DMS 497
Fall 2014

Bilateral Hydronephrosis and Ureterectasis to the Ureterovesical Junction


Hydronephrosis is a malformation described as urine dilatation of the structures within
the renal system. The development of hydronephrosis occurs due to either obstructive or
nonobstructive causes. Ureterectasis to the ureterovesical junction (UVJ) is a common
obstructive cause of bilateral hydronephrosis. Obstructive disorders inhibit the flow of urine
within the kidneys, and the condition can worsen as severity and duration of obstruction is
prolonged. The combination of clinical and sonographic findings together can help to determine
bilateral hydronephrosis with ureterectasis to the UVJ. Once the pathology is discovered, proper
treatment can be initiated.
Case History
This case describes a male infant with bilateral hydronephrosis and ureterectasis to the
UVJ. The examination was performed on a male that was delivered a few hours prior to the
ultrasound examination. The examination was performed because of an abnormal ultrasound
done while the baby was in utero, at 37 weeks gestational age. The mother had no known
previous history or prior surgeries performed. This was her first pregnancy. The final report of
the previous obstetric ultrasound described evidence of bilateral hydronephrosis with a normal
bladder and dilated ureters. The severity of hydronephrosis was documented as moderate. The
kidneys of the fetus appeared to be properly functioning due to the normal amniotic fluid index.
The patients mother was told about this possible pathology and it was recommended that the
baby be closely watched. She was also informed of the possible chromosomal abnormalities
associated with bilateral hydronephrosis. The only symptom observed at this time was that the
infant was frequently urinating. The patient had no labs available for review in her chart.

Creatinine and blood urea nitrogen levels are pertinent lab values to be reviewed, and in the case
of renal failure these levels would be elevated.1
Sonographic Findings
Sonographic images were taken, with a Toshiba ultrasound machine, hours after the baby
was born to further investigate the suspicious kidneys. Sagittal and transverse images were taken
in order to visualize the kidneys in their entirety and to adequately see the anechoic dilated renal
pelvis and calices. Measurements were taken of the length, width, and height of both kidneys. A
measurement of 9.8 millimeters was also taken in the sagittal plane to measure the renal pelvic
diameter of the right kidney; however, the sonographer did not measure the renal pelvic diameter
of the left kidney. A renal pelvic diameter of 9 to 15 millimeters in an anteroposterior dimension
is associated with moderate hydronephrosis.2 The normal ureter in a child is rarely over 5
millimeters3. Color Doppler was utilized to determine that the ureters did not have blood flow.
Color Doppler should have also been placed over the dilation seen in the central cavity of both
kidneys in order to prove that it was not vessels that were seen dilated. No spectral Doppler was
utilized because no blood flow was found in the ureters.
Sonographically, both renal pelvises and calices appeared dilated and anechoic with welldefined borders; however, there was still evidence of renal parenchyma bilaterally appearing
isoechoic to the liver. Both the right and left ureters appeared anechoic and dilated with a narrow
segment of the distal portion near the bladder, consistent with ureterectasis of the UVJ. The
bladder appeared anechoic without signs of trabeculation, or wall thickness.
Diagnosis
Based on the sonographic images provided, the previous examination, and the clinical
symptom, the infant appeared to have grade three or moderate bilateral hydronephrosis with

ureterectasis to the UVJ. Hydronephrosis is dilatation of the renal collecting system.2 Bilateral
simply means affecting both sides, or in this case both kidneys. The dilation may be caused by
obstruction, reflux, or abnormal muscle development.2 In this particular case the hydronephrosis
was caused from obstruction at the UVJ bilaterally. The word ureterectasis refers to dilation. This
particular dilation, due to obstruction, is seen at the ureterovesical junction where the ureters
meet the bladder.4 An obstruction in this area enables urine to reach the bladder causing the urine
to backup into the ureters and the kidneys.
Bilateral hydronephrosis occurs almost twice as frequently in boys than as in girls.5
Hydronephrosis is commonly seen in babies, and with many incidences the children who are
diagnosed prenatally, the condition disappears on its own by the time of birth or soon after.6
There are five different grades of hydronephrosis severity that were proposed by The Society for
Fetal Urology grading system. This grading system classifies the severity by the renal pelvic
diameter measured in the anteroposterior dimensions.2 The radiologist determined this specific
patient to have grade three or moderate bilateral hydronephrosis. According to The Society for
Fetal Urology grading system, measurements between 9 and 15 millimeters are considered
moderate.2 The sonographic images for this examination determined the right kidney to have a
renal pelvic diameter of 9.8 millimeters, which is consistent with moderate hydronephrosis. The
left kidneys pelvic diameter was not measured, but it should have been to determine the exact
severity of the hydronephrosis in that kidney.
The hydronephrosis has to have an area along the renal collecting system that is
obstructed or abnormal causing the urine output flow to back up into the kidneys. This particular
case was due to ureterectasis to the UVJ where the ureters meet the bladder. It was caused by
primary megaureter, where the juxtavesicular segment of the ureter near the bladder is narrowed

due to an increase in fibrous tissue or circumferential tissue that is lacking muscle.2 This
narrowing is not allowing adequate urine output; therefore, causing the urine to back up in the
direction in which it started. Vesticoureteral junction obstruction is more common in males and is
bilateral in up to 25% of cases.2 Primary megaureter is also found more often bilaterally and is
four times more common in boys than in girls.7 The term primary megaureter includes all
abnormalities related to a congenital alteration at the vescioureteric junction3.
The signs, symptoms, and sonographic findings of bilateral hydronephrosis and
ureterectasis to the UVJ intertwine. Most babies with hydronephrosis have no symptoms.6 The
baby normally does not present with symptoms because the hydronephrosis has resolved before
birth. Symptoms associated with ureterectasis to the UVJ and bilateral hydronephrosis include:
back or flank pain, abdominal pain, nausea and vomiting, bloody urine, fever, and frequent
urination.4 There are no risks associated with neither hydronephrosis nor its underlying causes;
nothing has been linked to anything parents did during pregnancy.6
Sonographically, the renal cortex appears isoechoic to the normal liver; this is the normal
appearance of the infant renal cortex. Less parenchyma than normal is seen due to the dilation of
the central anechoic cortex. Depending on the severity of the hydronephrosis will determine how
much of the parenchyma is visualized. According to The Society for Fetal urology grading
system, with grade three hydronephrosis all the calices are anechoic and dilated.2 The renal
pelvic diameter technique determines the hydronephrosis severity; measurements between 9 and
15 millimeters indicate moderate hydronephrosis.2 The anechoic dilation of the renal pelvic will
appear avascular with color Doppler and therefore no spectral Doppler is utilized. The ureters
appear anechoic and dilated with narrowing of the distal ureter behind the bladder. Increased

peristalsis in the ureters proximal to the obstruction may be seen in real time.2 Similar to the
kidneys, the ureters appear avascular without needing to utilize spectral Doppler.
Conclusion
This case had similar findings associated with bilateral hydronephrosis with ureterectasis
to the UVJ. This patient was in the common age range for this pathology, because it is most
commonly found in infants. Congenital hydronephrosis is almost always diagnosed on prenatal
sonography.8 Hydronephrosis and obstruction to the UVJ are both more common in males than in
females, and are found more often bilaterally. However, the patient did not present with all of the
symptoms associated with bilateral hydronephrosis and ureterectasis to the UVJ. The only
similar symptom documented for this patient was polyuria, or frequent urination. Also this exam
was performed one the day of the newborns birth. It is recommended that ultrasound not be
performed until 4 to 5 days after delivery to avoid a false negative diagnosis, by underestimating
the severity.8
Sonographically, the majority of the findings correlated with the sonographic findings
literature states are associated with grade three bilateral hydronephrosis and ureterectasis to the
UVJ. The calices of both kidneys were dilated and anechoic without color flow. The renal pelvic
diameter was measured for the right kidney of 9.8 millimeters, which is in the range of moderate
hydronephrosis. A variable amount of renal parenchyma was still visualized as isoechoic to the
adjacent liver. The ureters appeared anechoic, avascular, and dilated with a narrowing segment of
the distal portion of the ureter behind the bladder. The only sonographic differences with this
case compared to literature were there was no documentation of increased peristalsis in the ureter
proximal to the obstruction, and the left kidneys renal pelvic diameter was not measured. The

left kidney renal pelvic diameter is necessary to adequately determine the severity of the
hydronephrosis in that kidney.
After determining the pathology, along with the degree of severity and its cause,
treatment is the next step to take. The radiologist determined, from this ultrasound and the
obstetric ultrasound performed prior to the patients birth, that the bilateral hydronephrosis with
ureterectasis to the UVJ was not interfering with the renal function. In this situation many times
serial sonography can be performed at six month intervals.9 Surgery is normally not necessary
unless the hydronephrosis and obstruction to the UVJ is severe. Children who have mild or,
sometimes, moderate hydronephrosis, kidney function is often unharmed and the condition may
resolve itself over a period of time after delivery.6 In the case that the hydronephrosis and
obstruction to the UVJ need surgery, ureteral reimplantation is performed to remove the section
of the ureter that is abnormal, reducing it and reconnecting the ureter.4 Another treatment option
for patients with moderate or severe hydronephrosis is voiding cystourethrogram (VCUG) and
diuretic scintigraphy. VCUG assesses the presence of reflux and diuretic scintigraphy assesses
differential renal function. 8
As a sonographer, it is important to fully examine each kidney, the bladder, and ureters if
dilated when considering bilateral hydronephrosis and ureterectasis to the UVJ as the pathology.
Sonographers need to further evaluate the dilated ureters to determine if the hydronephrosis is
due to an obstruction or something that is not obstructive. The utilization of color Doppler should
always be used to detect the presence of blood flow where dilation is seen. Hydronephrosis and
ureterectasis to the UVJ would not show blood flow in that area. Measurement of both renal
pelvic diameters is important to document in order to determine the severity of the
hydronephrosis to each kidney. Ultimately, the severity will determine what treatment is

necessary and if renal function is present or restorable. It is important for the sonographer to be
knowledgeable of all associations with bilateral hydronephrosis or ureterectasis to the UVJ in
order to properly consider it as the pathology.

References
University of Michigan Health System. Vesicoureteral reflux. Ann Arbor, MI. 2014. Available
from: http://www.med.umich.edu/1libr/urology/vesicoureteral.htm
Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic ultrasound.4th edition.
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Glands p.1852-1856. Chapter 39, The Fetal Urogenital Tract p.1369-1373.
De Bruyn, Rose. Pediatric ultrasound: how, why, and when. Elsevier ltd. 2nd edition. 2010.
Chapter 3, The Renal Tract p.46.
Childrens Hospital of Philadelphia. Ureterovesical junction (UVJ) obstruction. Philadelphia, PA.
2011. Available from: http://www.chop.edu/healthinfo/ureteral-vesical-junctionobstruction.html
Cox LA, Lattimer JK, Uson AC. Journal of American medical association. Hydronephrosis in
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http://jama.jamanetwork.com/article.aspx?articleid=340166
Bostons Childrens Hospital. Hydronephrosis. Boston, MA. Available from:
http://www.childrenshospital.org/health-topics/conditions/hydronephrosis
Newson L. Congenital urogenital malformations. 2013. Available from:
http://www.patient.co.uk/doctor/congenital-urogenital-malformations
Siegel, MJ. Pediatric ultrasound. 4th edition. Philadelphia, PA. 2011. Chapter 11, Urinary Tract
p.393-396.
VanDervoort K, Lasky S, Sethna C, Frank R, Vento S, Choi-Rosen J, Goilav B, Trachtman H.
Clinical medicine: pediatrics. Hydronephrosis in infants and children: natural history
and risk factors for persistence in children followed by a medical service. 2009; 20(1):
6370. Available from: file:///C:/Users/sony/Downloads/f_1781-CMPed-Hydronephrosisin-Infants-and-Children-Natural-History-and-Risk-Facto.pdf_2494%20(1).pdf

CERTIFICATE OF AUTHORSHIP: I certify that I am the author of this research paper. I


have cited all of the sources from which I used data, ideas, or words (quoted or

paraphrased). I also certify that this paper was prepared by me specifically for this
course.
Signature _______Jennifer_Pittman_______________
Date:_____07/21/2014____________________
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