Hydronephrosis

Definition
 An aseptic dilatation of the renal pelvis
and calyces due to partial or intermittent
obstruction to the outflow of urine.
 Etiology
 It can be unilateral or bilateral
 Unilateral Hydronephrosis

Extramural Causes-
• Obstruction by renal vessels (vein or
artery)
• Compression by growth (CA cervix or
carcinoma rectum)
• Retroperitoneal fibrosis
 Intramural causes-
• Congenital pelviuretric junction obstruction
• Ureterocele
• Neoplasm of ureter
• Narrow ureteric orifice
• Stricture ureter following removal of stone,
pelvic surgeries or tuberculosis of ureter
Intraluminal causes-
• Stone in the renal pevis or ureter
• Sloughed papilla in papillary
necrosis
 Bilateral Hydronephrosis

Congenital causes

• Congenital stricture of external urethral

meatus or pin-hole meatus
• Congenital posterior urethral valve
 Acquired causes
• BPH
• Carcinoma prostate
• Bladder carcinoma
• Inflammatory/traumatic urethral stricture
• Phimosis
• Postoperative bladder neck scarring
• Carcinoma cervix
Obstructive lesions of the urinary tract
 Pathophysiology
 Anatomic and functional processes interrupts
the flow of urine
 There is raise in ureteral pressure causing
stretching and dilatation; if pressure continue to
raise, it leads to decline in renal blood flow and
GFR
 When significant obstruction is persistent, it
affects renal tissue and results in varying
degrees of cystic dysplasia and renal impairment
Obstruction can be sudden or insidious, partial
or complete, unilateral or bilateral

May occur at any level from urethra to the

renal pelvis

Obstruction increases succeptibility to infection

and to stone formation

Unrelieved obstruction almost always leads to

permanent renal atrophy
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 secretory function gets

compromised

Parenchymal thickness of less thn 2mm is

unlikely to function.in bilateral cases such
patients go for renal failure
 The high pressure in the pelvis is transmitted back through
the collecting ducts into the cortex, causing renal atrophy

 It also compresses the renal vasculature of the medulla,

causing a diminution in inner medullary blood flow
 The medullary defects are reversible initially but lead to
medullary functional disturbances

 The initial functional alterations caused by obstruction are

largely tubular, manifested primarily by impaired
concentrating ability

 Only later the GFR begins to fall

 Obstruction also triggers an interstitial inflammatory

reaction leading eventually to interstitial fibrosis
The kidney may be slightly to massively enlarged,
depending upon the degree and duration of the
obstruction
Earlier features are dilatation of renal pelvis and
the calyces with significant interstitial inflammation
In chronic cases the picture is one of cortical
tubular atrophy with marked diffuse interstitial
fibrosis
Progressive blunting of the apices of pyramid occurs
and eventually becomes cupped
In advanced cases,kidney may become cystic
structure having a diameter of 15-20cm
 Stages of Hydronephrosis

cup flat club broadened

 types of renal pelvis

Intrarenal

extrarenal
 Extrarenal pelvis refers to the presence of the renal
pelvis outside the confines of the renal hilum. It is a
normal variant that is found in ~10% of the
population .

 The renal pelvis is formed by all the major calyces. An

extarenal pelvis usually appears dilated giving a false
indication of an obstructive pathology. Subsequent
investigation with CT, usually clarifies the false
interpretation on ultrasound.