Hidronefrosis PDF

March 2006
Sarah Psutka, 2007

Gillian Lieberman MD
Unequivocal Obstructive Uropathy

Radiologic Assessment
Sarah P. Psutka
Harvard Medical School Year III
Sarah P. Psutka, 2007
Goals
Review Anatomy: Urinary Tract
Define Unequivocal Obstructive Uropathy
Pathophysiology
Pathology
Clinical Presentation
Patient KA
Patient JL
Patient JM
Radiologic Work-up Modalities
Management
2
Anatomy: Urinary Tract

Renal Capsule
Calyx
Cortex Superior
Operculum
Medulla
Papilla
Pelvis
Inferior
Operculum
Fornix
Medline Plus: Medical Encyclopedia: Female Urinary System http://www.urostonecenter.com/images/p1.gif

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1122.htm
3
Unequivocal Obstructive Uropathy
= Urinary tract obstruction
Unequivocal: clear etiology

Obstruction may be at
any site within GU tract
Evidence of post-renal
failure
Variable presentation
based on etiology
Hydronephrosis
Hydronephrosis
http://www.merck.com/media/mmhe2/figures/fg148_1.gif
http://www.e-radiography.net/ibase5/Renal/slides/
Renal_ca_bladder_hydronephrosis_rt_ivu.jpg
Sign: Hydronephrosis = dilatation of renal pelvis and ureters

4
Pathophysiology of Obstructive Uropathy

Hydronephrosis
Mechanical or functional obstruction
Back up of urine flow = increased renal pressure
Tubular dilatation
Initial increase in renal blood flow
Decrease in renal blood flow
Increase in renal lymphatic flow
Initial increase in ureteral peristalsis & pelvic

muscle hypertrophy
Muscle stretched & atonic Aperistalsis
Dilatation of ureters and renal collecting duct system
Parenchymal Atrophy
Renal failure 5
Pathogenesis of unilateral hydronephrosis. Smiths Urology p.181
How Acute Obstruction leads to

Dilatation and Decreased Tubular
Function
6
Blandino et al., AJR 2002; 179: 1307 -1314
http://asia.elsevierhealth.com/home/sample/pdf/314.pdf
Pathology
Dilated renal pelvis (arrow), external view Dilated pelvis & calyces, renal atrophy, cut surface
http://www.smbs.buffalo.edu/pth600/IMC- http://www.smbs.buffalo.edu/pth600/IMC- 7
Path/y1case/y1ans21.htm#Obstructivelesionsintheurin Path/images/Year1/Hydronephrosis_Gross-_Robbins.jpg
arytract
Clinical Presentation: Obstructive Uropathy

Lower and Mid Tract Upper Tract
(Urethra and Bladder) (Ureter and Kidney)
Hesitancy in starting urination Flank pain radiating along ureter
Lessened force course (distension)
Weak stream Gross hematuria
Terminal dribbling Nausea/Vomiting
Hematuria Fever/Chills
Burning on urination Burning on urination
Cloudy urine (infection) Cloudy urine with infection
Acute urinary retention Bilateral uremia
N/V/weight loss
Renal insufficiency Consider UTO in all patients with unexplained renal insufficiency
Urine Output Changes
Anuria = complete bilateral UTO
Partial obstruction normal to elevated UO
Hyperkalemic renal tubular acidosis
Hypertension
Lab Abnormalities: normal, microscopic/gross hematuria, pyuria, azotemia, uremia,
anemia (2/2 chronic infection, ACD), leukocytosis
8
Presentation: Patient KA
65 yo male c/o several days of
hematuria and back pain.
Exam: MM dry, enlarged
prostate, difficult foley Renal Failure
placement, minimal urine
output (30cc following 1 L IVF) Oliguria
U/A: Large blood, + nitrite,
protein > 300mg/dL, glucose Infection
100, ketones 15 mg/dL, large
bilirubin, Urobilin 4 mg/dL, pH Hematuria
6.5, large leukocytes
WBC: 6.2
Hgb: 11.2
Cr: 8.4 (baseline 1.4)
9
Presentation: Patient JL
57 yo male with history of bladder
CA, renal stones, presents with
severe L flank pain. s/p TURBT
for bladder CA.
Exam: no CVA tenderness, no Hematuria
abdominal tenderness, normal Flank Pain
sized prostate
Renal function
Labs:
unperturbed
Cr = 1.3
Hgb = 15.4 WBC = 11.7
U/A: large blood
10
Presentation: Patient JM
27 yo male with h/o left

ureter stenosis presents
with severe left sided flank
pain. Flank Pain
Exam: unremarkable
Renal function
U/A: clear yellow urine, neg unperturbed
dipstick
WBC: 12.8
11
Differential Diagnosis: Obstructive Uropathy

In The Lumen
Sloughed papillae/blood clots
Urinary calculi Young Adults
Infection
Intrinsic/Congenital
Urethral valves
Urethral strictures
Meatal stenosis Children
Bladder neck obstruction
Ureteropelvic junction stenosis/obstruction
Ureterovesical junction stenosis/obstruction
Ureteric Strictures : infectious, iatrogenic, XRT, TB
Severe vesicoureteral reflux
Extrinsic
Benign prostatic hypertrophy (BPH)
Tumors - carcinoma of the prostate, bladder tumors, contiguous malignant disease,
transitional cell carcinoma of renal pelvis/ureters/bladder, squamous carcinoma
of the cervix, retroperitoneal lymphomas Older patients
Inflammation
prostatitis, ureteritis, urethritis,
retroperitoneal fibrosis
Idiopathic, B-blocker/methysergide use, malignancy, connective
tissue disorder
Uterine prolapse or cystocele
Endometriosis
Fibrosis around renal transplant
Dilatation without obstruction
Gram neg cocci in pyelonephritis dilatation due endotoxin
Pregnancy 12
Chronic obstruction post-release
Mega-ureter
Think Anatomically:
Where is obstruction?
Proximal
etiology
Series: 53 of 380 patients
52/53 in lower 1/3 of the ureter.
Unilateral Causes:
hydronephrosis
Ureteral stones 64%
Most Common in Distal Ureter Ureteral edema or lucent
stones 30%
Systemic or Neoplasms 4%
Distal etiology Inflammatory disease 2%

Chen et al., J Emerg Med, 1997: 15; 3. 339 343.
Bilateral
hydronephrosis
13
Obstructive lesions of the urinary tract that cause hydronephrosis from Robbins & Cotran, 7th Ed, Chap 20, p 1013
Acute Obstruction and Anuria

Acute complete, bilateral obstruction
= Medical Emergency
Patients may die from acute

renal failure with
oliguria/anuria
Requires prompt
recognition and
possible surgical
intervention
CT examination: Postcontrast axial scan: The retroperitoneal giant tumor mass compresses the
right ureter and causes hydronephrosis (arrows). 14
http://www.szote.u-szeged.hu/radio/panc/alep8c.htm
Diagnosis
Early diagnosis and decompression is

critical to prevent renal failure
Continue to Radiologic work-up
15
Ultrasonography
Test of Choice for Suspected Urinary Tract Obstruction
Screening test
Indications: Renal failure of unknown origin/Hematuria/Signs of UTO/Urolithiasis
Sensitivity for detection of chronic obstruction: 90%
Sensitivity for detection of acute obstruction: 60%
Advantages:
No allergic/toxic complications of radiocontrast media
Fast, inexpensive
Diagnose other causes of renal disease in patient with renal insufficiency of
unknown origin
Polycystic Kidney Disease
Disadvantages
Nonspecific
Rarely identifies cause
False positive rate: < 25% with minimal criteria (operator dependent)
Any visualization of collecting systems
False negative with acute obstruction, dehydration, sepsis
Bowel Gas decreases sensitivity
16
Ultrasound Normal Kidney
Normal renal
parenchyma,
hypoechoic,
normal function
Normal renal fat,

no dilatation of
collecting
system,
hyperechoic
17
Pt. AK, PACS, Courtesy of Dr. AC Kim
Ultrasound Obstructive Uropathy
Renal
parenchyma,
hypoechoic
Dilated collecting
duct, hypoechoic
(fluid)
Compressed
renal fat,
hyperechoic
18
Pt. AK, PACS, Courtesy of Dr. AC Kim
Abdominal CT & Plain Film

1. CT
***Noncontrast*** Limitations of Plain Film and CT
Urolithiasis test of choice in ED Obstruction due to radiolucent
Size stones (indinavir), sloughing of
Location renal papillae, small blood clot
Identify masses/Inflammation causing Radiation doses
extrinsic obstruction Need Fat to see soft tissue
Identify obstructive atrophy
Quick Contraindications to Contrast
Post Trauma Pregnancy, children, nursing
moms
2. Plain Film Renal failure/insufficiency
Enlarged renal shadows Allergy
Heavy metal densities renal stones Multiple Myeloma
Tumor metastases to bones of CHF
spine/pelvis Gout
Osteoblastic? Likely prostate
metastases
CT/Plain film + ultrasound will make the

diagnosis of ureteral obstruction in ~90% cases 19
CT: normal renal parenchyma with

proximal stone, no obstructive uropathy
Noncontrast
CT
Enhancing
calculus in
interpolar
portion of R
Kidney
Kawashima et al., RadioGraphics 2004;24:S35-S54
20
CT: Hydronephrosis due to

retroperitoneal fibrosis (soft tissue)
CT (postcontrast):
Giant retroperitoneal
tumor mass
compressing the right
ureter, causing
hydronephrosis with
compression of renal
parenchyma (arrows).
21
CT: Obstructive Uropathy

Dilated Renal
Pelvis
Proximal
Stone
CT (postcontrast):
Obstructive left-sided
uropathy with
proximal ureteric
stone
22
PACS, Courtesy of Dr. D. Brennan
IVU: Intravenous Urogram

Intravenous Pyelogram = Excretory Urogram
1. Scout film calculi?
2. IV bolus of radiocontrast dye (ionic contrast)
3. Series of plain films demonstrate kidneys, ureters,
urinary bladder
4. Upright film post-void to evaluate for obstruction
Advantages
Anatomy
Pathology Location
Rough indicator of function bilaterally
Low false positive rate
Detects associated conditions
Papillary necrosis intralumenal filling defect
Caliceal blunting from previous infection
Disadvantages
Cumbersome
Requires radiocontrast http://www.e-
radiography.net/ibase5/Renal/slides/Renal_ca_bladder_hy
Need bowel prep with conventional IVU dronephrosis_rt_ivu.jpg
Radiation dose
Need cross-sectional imaging follow up 23
CT Urography
Evaluate urinary tract for flow defects
Noncontrast Scout first: Urolithiasis
Coronal reconstructions: visualize entire urinary tract
Advantages over Conventional IVU

Speed
Sensitive to renal parenchyma abnormalities
Simultaneous evaluation of both renal parenchyma and
urinary tract
Cross-sectional imaging
Disadvantages
Radiation dose
Ionic Contrast reactions/cannot be used in patients in
renal failure
Kawashima et al., RadioGraphics 2004;24:S35-S54
24
Normal CT Urogram
CT Urography
Total Body
Opacificantion
Nephrogram
Pyelogram
25
Pt. JL, PACS, Courtesy of Dr. AC Kim
Normal CT Urogram
CT Urography
Total Body
Opacificantion
Nephrogram
Pyelogram
26
Normal CT Urogram
CT Urography
Total Body
Opacificantion
Nephrogram
Pyelogram
27
Normal CT Urogram
CT Urography
Total Body
Opacificantion
Nephrogram
Pyelogram
28
Normal CT Urogram
CT Urography
Total Body
Opacificantion
Nephrogram
Pyelogram
29
Normal CT Urogram
CT Urography
Total Body
Opacificantion
Nephrogram
Pyelogram
30
Normal CT Urogram
CT Urography
Total Body
Opacificantion
Nephrogram
Pyelogram
31
Contraindications for IVU/CTU

History of allergy to IV contrast
Bronchospasm, laryngeal edema, anaphylactic shock
May use with history of minor allergic reactions with preprocedural steroids,
antihistamines (diphenhydramine) 12 hours prior to study
Renal insufficiency
Pregnancy = relative contraindication (radiation exposure)
MR Urogram can be used
Likewise: children minimize radiation doses
Pts taking oral hypoglycemics (metformin) should stop taking meds prior to
study
May resume after renal function is confirmed normal
Risk of lactic acidosis
Must be Physician-Supervised
- Contrast reactions
- Minimize no. of images
- Minimize radiation
- May use Fluoroscopy 32
MR Urography
Sagittal contrast-enhanced excretory
MR urography obstructing right
A. Unenhanced MR urography sided papillary TCC
Heavily T2 weighted
B. Gadolinium-enhanced excretory MR urography
C. Excretory MR urography + diuretic
10 mg furosemide IV
Gadopentetate dimeglumine
Advantages:
Distinguishes adjacent soft tissue abnormalities
With Gadolinium: functional information
No ionic contrast OK in renal failure
No radiation children, pregnancy women
Drawbacks
High cost
Low sensitivity in detecting calcifications
Time intensive
Metallic implants/Foreign Body = Contraindications 33
Excretory Urogram/CTU/MRU
Acute Obstruction
Mild Moderate Marked

Kidney minimally enlarged
Dense Nephrogram
Preferential absorption of Na and
water from diseased tubules =
concentration of contrast
Delayed appearance of contrast in
collecting system
= delayed function
Poor concentration of contrast in the
collecting tubules
No ureteral dilatation acutely
Ureters not tortuous
http://asia.elsevierhealth.com/home/sample/pdf/314.pdf 34
Excretory Urogram/CTU/MRU
Chronic Obstruction
Partial Complete
Progressive dilation of collecting system Calyceal Clubbing
and ureters/tortuous
Urectasis = dilated ureter
Decrease number of nephrons
6-12 weeks: irreversible loss of renal
function
Shell nephrogram parenchymal
atrophy
Collecting system: blunt calyces/forniceal
angles

35
Evaluation of Renal Function: Renal Scan

Renal scan = Renogram =
Nephrogram
Nuclear medicine examination
using radioisotopes (Tc-99m
DPA) to measure kidney filtration
of blood
Findings indicative of decreased renal

function
Delayed appearance of
radionuclide
Diminished uptake compared
with normal side
Dilated collecting system and http://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.html
ureter to point of obstruction Lasix Renogram
on delayed scans
Advantages Prompt excretion of activity from
No contrast the right kidney, but an obstructed
pattern on the left side 36
Evaluation of Renal Function: Renal Scan

Renal scan = Renogram =
Nephrogram
Nuclear medicine examination
using radioisotopes (Tc-99m
DPA) to measure kidney
function
Findings indicative of decreased renal

function
Delayed appearance of
radionuclide
Diminished uptake compared
with normal side
Dilated collecting system and http://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.html
ureter to point of obstruction Lasix Renogram
on delayed scans
Advantages Prompt excretion of activity from
No contrast the right kidney, but an obstructed
pattern on the left side 37
Patient KA: Work-up
Hypoechoic fluid
filling renal pelvis
Pt. KA, PACS, Courtesy of Dr. AC Kim
Ultrasound
Bilateral Mild Hydronephrosis
Right Kidney 11.9 cm (baseline 10.6 cm)
Left Kidney 12.7 cm (baseline 11.0 cm)
Normal flow bilaterally (seen on Doppler) 38
Patient KA
Bilateral Hydronephrosis with

dilatation of renal pelvis
Perirenal fat
stranding

39
Patient KA: NSAID overdose leading to papillary

necrosis and UTO, with secondary infection
Diagnosis:
65 yo M with mild bilateral
hydronephrosis, hydroureter,
and fat stranding in the setting
of acute post-renal failure and
Hydroureter oliguria. Believed to be
secondary to excessive NSAID
use, causing renal papillae
necrosis and sloughing and
acute prostatis.
Management
Admitted
Cystoscopy: R UO Sludge
No evidence of stone Ureteral stents placed
Pain Management
Antibiotics for UTI and 40
Prostatitis
Patient JL: Workup
Enlarged
kidney
Mild hypoechogenic
renal pelvis

41
Patient JL Left Hydronephrosis
Small cyst
Left Hydronephrosis
Mild Fat Stranding
42
Patient JL Bladder Mass

Diagnosis:
Left Bladder mass
surrounding UO 57 yo M with known Bladder
CA with left hydronephrosis
secondary to left bladder
cancer.
Management
Foley placement for
immediate decompression.
Pt urinated following
catheter removal and was
cleared for d/c
Urology consult for possible
stent placement
43
Patient JM: Workup
Massive
Hydronephrosis
44
Pt. JM, PACS, Courtesy of Dr. AC Kim
Patient JM
Proximal renal
pelvis dilatation
without dilatation
of distal ureter
Fat
stranding
45
Patient JM
Proximal renal
pelvis dilatation
without dilatation
of distal ureter
Fat
stranding
46
Patient JM
Parenchymal
thickness
preserved
No
visible
stone
47
Patient JM: Severe Hydronephrosis

Seconday to Ureter Stenosis
Diagnosis:
27 yo M with severe right
hydronephrosis likely due to
congenital left ureter
stenosis
Found to have
simultaneous UTI
Management
Pain Control
Antibiotics
Referred to Urology for out-
patient ureteral stent
placement
Pt. JM, PACS, Courtesy of Dr. AC Kim 48
Urinary Tract Obstruction

Without Hydronephrosis
CAVEAT:
Normal Kidney Appearance in the
UTO can occur without setting of acute obstruction
hydronephrosis or dilatation
of the urinary tract
1. Acute: Days 1 - 3
Duplex Doppler U/S
detect increased resistive
index vs. contralateral
kidney
2. Mild obstruction without
impairment of renal Pt. AK, PACS, Courtesy of Dr. AC Kim
function
49
Hydronephrosis without Obstruction/

with Asymptomatic Obstruction
Presentation: Back/flank pain, hematuria,
hydronephrosis and ureteral dilatation
Etiologies
Pregnancy (normal finding)
Megaureter due to previous Vesicoureteral reflux
Dilated but unobstructed extrarenal pelvis
Gram Negative Cocci infection (Endotoxin)
Goal: Rule out obstruction
1. Diuretic Renogram
2. Diuretic IVU
3. Whitaker Test/Perfusion pressure flow
studies
21 yo M with L Megaureter,
No obstruction 50
Radiologic Work-up for Urinary Tract

Obstructive Obstruction: Rationale
Symptoms
Flank pain
Hematuria Is there Is there mechanical What is renal
Renal failure hydronephrosis? obstruction? function?
Dysuria/Frequency
Urgency
Ultrasound CT IVU/CTU/MRU
Plain Film Renal scan/Nephrogram
No: Yes/Equivocal with

Alternate Answer
High Clinical Final Diagnosis
Work-up Where is it?
Suspicion
Management:
Decompression
Urology Consult
Cystoscopy
51
Management of Urinary Tract Obstruction

Surgery Percutaneous Nephrostomy Tube
Nephrectomy Emergency Drainage
Partial Nephrectomy
Resect extrinsic masses
Intraureteral Stone removal Ureteral Stents

Extracorporeal Shock Wave Lithotripsy
Laser Lithotripsy
Percutaneous Ultrasonic Lithotripsy
Cystoscopy
TURB
Prostate resection/TURP/PVP
Foley Catheter
52
Obstructive lesions of the urinary tract that cause hydronephrosis from Robbins & Cotran, 7th Ed, Chap 20, p 1013
References
Alpers CE. The Kidney in Robbins and Cotrans Pathologica Basis of Disease. Eds Kumar, Abbas, Fausto. Elsevier-
Saunders 7th Ed. Pennsylvania 2005. pp. 955 1021.
Barbaric ZL. Urinary Tract Obstruction in Principles of Genitourinary Radiology. Thieme Medical Publishers, Inc. New
York. 1999. p 111 151.
Blandino et al., MR Urography of the Ureter: Pictoral Essay. AJR 2002; 179: 1307-1314.
Chen, M et al., Radiologic findings in Acute Urinary Tract Obstruction. J Emerg Med 1997; 15:3: 339 343.
Kawashima et al., CT Urography. RadioGraphics 2004;24:S35-S54
Rose BD. Diagnosis of urinary tract obstruction and hydronephrosis. UpToDate 2006.
Tanagho JW and McAninch EA. Urinary Obstruction and Stasis in Smiths General Urology. Lange Medical
Books/McGraw Hill 16th Ed. New York, 2004. p 175 187.
Weissleder R et al. Obstruction of Collecting System in Primer of Diagnostic Imaging. Mosby 3rd Ed. Boston, 2003.
Zagoria RJ and Tung GA. The Renal Sinus, Pelvocalyceal System and Ureter in Genitourinary Radiology The
Requisites. Mosby Publishers, Inc. St. Louis, Missouri. 1997. p.152 191.
Websites:
Hematuria Cases Liebermans Primary Care Radiology: Dr. G. Lieberman
http://www.primarycareradiology.com
Hydronephrosis Medline Plus
http://www.nlm.nih.gov/medlineplus/ency/article/000509.htm#Alternative%20Names
Diuresis Renogram Joint Program in Nuclear Medicine
http://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.html
Hydronephrosis Pathology Cases
http://www.smbs.buffalo.edu/pth600/IMC-Path/y1case/y1case21.htm
OReilly, P. Upper Tract Obstruction Benign Disorders of the Upper Urinary Tract.
http://asia.elsevierhealth.com/home/sample/pdf/314.pdf
Hydronephrosis
http://www.e-radiography.net/ibase5/Renal/slides/Renal_ca_bladder_hydronephrosis_rt_ivu.jpg
CT Urography
53
Many Thanks!
Darren Brennan, MD, BIDMC

AC Kim, MD, BICMC
Andrew Bennett, MD, BIDMC
Gillian Lieberman, MD, BIDMC
Pamela Lepkowski, BIDMC
Larry Barbaras, Webmaster, BIDMC
54

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March 2006

Sarah Psutka, 2007

Unequivocal Obstructive Uropathy

Anatomy: Urinary Tract

Medline Plus: Medical Encyclopedia: Female Urinary System http://www.urostonecenter.com/images/p1.gif

Unequivocal Obstructive Uropathy

= Urinary tract obstruction

Unequivocal: clear etiology

Sign: Hydronephrosis = dilatation of renal pelvis and ureters

Pathophysiology of Obstructive Uropathy

Back up of urine flow = increased renal pressure

Initial increase in renal blood flow

Decrease in renal blood flow

Increase in renal lymphatic flow

Initial increase in ureteral peristalsis & pelvic

Dilatation of ureters and renal collecting duct system

How Acute Obstruction leads to

Clinical Presentation: Obstructive Uropathy

27 yo male with h/o left

Differential Diagnosis: Obstructive Uropathy

Distal etiology Inflammatory disease 2%

Acute Obstruction and Anuria

Patients may die from acute

Early diagnosis and decompression is

Continue to Radiologic work-up

Ultrasound Normal Kidney

Normal renal fat,

Ultrasound Obstructive Uropathy

Abdominal CT & Plain Film

CT/Plain film + ultrasound will make the

CT: normal renal parenchyma with

Kawashima et al., RadioGraphics 2004;24:S35-S54

CT: Hydronephrosis due to

CT: Obstructive Uropathy

IVU: Intravenous Urogram

Advantages over Conventional IVU

Kawashima et al., RadioGraphics 2004;24:S35-S54

Contraindications for IVU/CTU

Mild Moderate Marked

Blandino et al., AJR 2002; 179: 1307 -1314

Evaluation of Renal Function: Renal Scan

Findings indicative of decreased renal

Evaluation of Renal Function: Renal Scan

Findings indicative of decreased renal

Patient KA: Work-up

Pt. KA, PACS, Courtesy of Dr. AC Kim

Bilateral Hydronephrosis with

Pt. KA, PACS, Courtesy of Dr. AC Kim

Patient KA: NSAID overdose leading to papillary

Patient JL: Workup

Pt. JL, PACS, Courtesy of Dr. AC Kim

Patient JL Left Hydronephrosis

Mild Fat Stranding

Patient JL Bladder Mass

Patient JM: Workup

Patient JM: Severe Hydronephrosis

Urinary Tract Obstruction

Hydronephrosis without Obstruction/

Radiologic Work-up for Urinary Tract

No: Yes/Equivocal with

Management of Urinary Tract Obstruction

Intraureteral Stone removal Ureteral Stents

Darren Brennan, MD, BIDMC