From the Guidelines
Hydronephrosis with pelvolithiasis on ultrasound requires prompt urological evaluation and management, which depends on stone size, location, and symptom severity, with the goal of preventing permanent kidney damage and improving quality of life. The diagnosis of hydronephrosis and pelvolithiasis is often made using ultrasound, which is highly sensitive for detecting hydronephrosis and bladder distension, allowing localization of the level of obstruction and guiding intervention 1.
Initial Evaluation
The initial evaluation of hydronephrosis of unknown etiology is complex and dependent on clinical context, with CT urography (CTU) without and with contrast, MR urography (MRU) without and with contrast, or scintigraphic evaluation with mercaptoacetyltriglycine (MAG3) imaging being recommended for asymptomatic patients 1. For symptomatic patients, CTU without and with contrast, MRU without and with contrast, MAG3 scintigraphy, or ultrasound of the kidneys and bladder with Doppler imaging are all viable initial imaging studies 1.
Management
Management of hydronephrosis with pelvolithiasis depends on stone size, location, and symptom severity, with conservative treatment including oral hydration, pain control with NSAIDs, and medical expulsive therapy with tamsulosin being recommended for stones <10mm with mild-moderate hydronephrosis and manageable pain 1. Stones >10mm, severe hydronephrosis, intractable pain, infection, or kidney dysfunction require interventional approaches such as extracorporeal shock wave lithotripsy, ureteroscopy with laser lithotripsy, or percutaneous nephrolithotomy 1.
Prevention
Prevention strategies include dietary modifications, increased fluid intake, and possibly medications like thiazide diuretics, potassium citrate, or allopurinol based on stone composition, with the goal of reducing the risk of recurrent stone formation and improving quality of life 1. Patients should strain urine to collect passed stones for composition analysis, and follow-up imaging (ultrasound or CT) is essential to confirm stone passage and resolution of hydronephrosis 1.
Key Considerations
Key considerations in the management of hydronephrosis with pelvolithiasis include the risk of permanent kidney damage if left untreated, as well as the potential for infection or scarring, highlighting the importance of prompt and effective treatment 1. The use of color Doppler to assess global perfusion and confirm arterial and venous patency is also an important consideration in the evaluation and management of hydronephrosis with pelvolithiasis 1.
From the Research
Diagnosis of Hydronephrosis and Pelvolithiasis
- Hydronephrosis can be diagnosed using various modalities, including sonography, radiography, magnetic resonance imaging, and nuclear medicine technology 2.
- Ultrasound scanning is a common method for diagnosing hydronephrosis, and its increased availability has led to more frequent diagnoses 3.
- Nephrolithiasis, or kidney stones, can be diagnosed using imaging techniques such as CT scans, and its diagnosis is pertinent to general surgeons due to its potential to present as a general surgical condition 4.
Management of Hydronephrosis and Pelvolithiasis
- The management of hydronephrosis involves understanding its aetiology, clinical presentation, and diagnosis, as well as its treatment options 3.
- Extracorporeal shock-wave lithotripsy (ESWL) is a treatment option for proximal ureteral calculi, and its efficacy can be affected by the degree of hydronephrosis 5.
- The severity of hydronephrosis can clarify prognosis and guide management for emergency department patients with acute ureteral colic, with severe hydronephrosis being an important finding that warrants definitive imaging and referral 6.
- The presence of hydronephrosis can be associated with repeat treatment and prolonged clearance time in patients with solitary lumbar ureter stones 5.
Grading and Treatment of Hydronephrosis
- A grading scale for hydronephrosis can be used to assess its severity, and treatment options can be explained based on this grading scale 2.
- The degree of hydronephrosis can affect the treatment outcome of ESWL, with stones in obstructed systems being associated with a tendency for repeat treatment and a prolonged time for stone clearance 5.
- Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value, and more granular hydronephrosis grading is not prognostically helpful 6.