What is the treatment for hydronephrosis?

Treatment of Hydronephrosis

The treatment of hydronephrosis requires prompt decompression of the collecting system, preferably via percutaneous nephrostomy (PCN) or retrograde ureteral stenting, to prevent permanent renal damage. 1, 2

Diagnostic Approach

• Initial imaging: CT urography is the preferred initial imaging study for adults with severe hydronephrosis, providing comprehensive visualization of both upper and lower urinary tracts 2
• Laboratory tests: Check serum creatinine to assess renal function impairment 2
• Identify underlying cause: Common etiologies include:
  • Urolithiasis
  • Malignant obstruction
  • Ureteropelvic junction obstruction
  • Strictures
  • Retroperitoneal fibrosis
  • Extrinsic compression
  • Bladder outlet obstruction 1, 2

Treatment Algorithm

1. Emergency Management (Infected Hydronephrosis/Pyonephrosis)

• Immediate decompression is mandatory to prevent life-threatening sepsis 2
• PCN or retrograde ureteral stenting are both effective options 1, 2, 3
• Antibiotic therapy should be initiated promptly 1
  • Third-generation cephalosporins (ceftazidime) have shown superiority over fluoroquinolones (ciprofloxacin) in clinical and microbiological cure rates 1
• PCN advantages:
  • Higher technical success rate (>95% for dilated systems) 1
  • Better for pyonephrosis when larger tube decompression is warranted 1
  • Provides direct access for bacteriological sampling 1
• Retrograde stenting advantages:
  • Better tolerated by patients (no external catheter) 1
  • May be preferred for patients at low risk for anesthesia 1

2. Non-Emergency Management

• Obstructive hydronephrosis without infection:
  • PCN or retrograde ureteral stenting based on:
    • Patient's clinical condition
    • Accessibility of the ureter
    • Local expertise 1, 2
  • Follow with definitive treatment of underlying cause 1

3. Specific Scenarios

Malignant Obstruction

• Long-term decompression with ureteral stent or PCN 2
• Treatment of underlying malignancy 2
• Regular monitoring of renal function 2
• Periodic replacement of stents or nephrostomy tubes as needed 2

Urinary Diversion After Cystectomy

• PCN followed by conversion to retrograde percutaneous nephroureteral catheter 1
• Avoid internal double-J stents as they quickly become occluded with mucus in ileal conduits 1

Pregnancy-Related Hydronephrosis

• Asymptomatic cases (70-90% of pregnant patients): typically require no intervention 1
• Symptomatic cases (0.2-4.7%): retrograde ureteral stenting with minimal or no fluoroscopy 2
• PCN as alternative when retrograde stenting not technically possible 2
• Untreated symptomatic cases can lead to preterm labor or maternal/fetal death 1

Pediatric Hydronephrosis

• Initial ultrasound 48-72 hours after birth for antenatal hydronephrosis 2
• Follow-up based on severity 2
• Consider VCUG for moderate to severe cases to rule out vesicoureteral reflux 1, 2
• Antibiotic prophylaxis may be considered for moderate to severe cases 2

Post-Intervention Care

• Follow-up imaging (ultrasound) to confirm resolution of hydronephrosis 2
• Regular monitoring of renal function with serial creatinine measurements 2
• Diuretic renography (MAG3 scan) to evaluate drainage and differential renal function 2

Complications to Monitor

• Acute kidney injury
• Urinary tract infection/urosepsis
• Permanent nephron loss
• Hypertension
• Growth retardation (in pediatric cases) 2

Pitfalls and Caveats

• Delay in treatment of infected hydronephrosis can lead to life-threatening sepsis 2
• Lower urinary production in the immediate postnatal period can mask urinary tract abnormalities in infants 1
• Radiation exposure should be minimized during interventions, especially in pregnant patients 2
• Retrograde stenting may be associated with higher risk of urosepsis in patients with extrinsic ureteral obstruction 1