What is the next step in management for a patient with hydronephrosis, hydroureter, and hematuria found on a computed tomography (CT) scan with contrast?

Management of Hydronephrosis, Hydroureter, and Hematuria

For a patient with hydronephrosis, hydroureter, and hematuria found on CT scan with contrast, urologic consultation for cystoscopy and possible urinary tract decompression is the next appropriate step in management.

Risk Assessment and Diagnostic Considerations

When evaluating a patient with this clinical presentation, it's important to recognize the potential urgency of the situation:

• The combination of hydronephrosis, hydroureter, and hematuria suggests urinary tract obstruction, which can lead to renal damage if not addressed promptly
• CT with contrast has already confirmed the anatomical abnormalities, providing valuable information about the location and possible cause of obstruction
• Hematuria in this context may indicate:
  • Urolithiasis (kidney or ureteral stones)
  • Urinary tract malignancy
  • Blood clot causing obstruction
  • Congenital anomalies (less common in adults)

Management Algorithm

Immediate Assessment:

1. Evaluate vital signs and assess for signs of infection (fever, flank pain)
2. Review laboratory values:
   • Complete blood count
   • Renal function (BUN, creatinine)
   • Urinalysis (quantify hematuria, check for pyuria)
   • Urine culture if infection suspected

Next Steps Based on CT Findings:

• If stone identified as cause of obstruction:

  • Size and location determine management
  • Stones <5mm may pass spontaneously with medical expulsive therapy
  • Stones >5mm or causing severe obstruction require urologic intervention

• If no stone identified:

  • Consider other causes of obstruction (tumor, blood clot, stricture)
  • Cystoscopy with possible retrograde pyelography is indicated 1

Urologic Consultation:

• Immediate consultation is warranted for:
  • Signs of infection with obstruction (potential pyonephrosis)
  • Acute kidney injury
  • Intractable pain
  • Bilateral obstruction

Interventional Options

Based on the American College of Radiology guidelines, the following interventions may be considered 1:

1. Cystoscopy: Essential to evaluate the lower urinary tract for source of hematuria and to assess ureteral orifices

2. Ureteral stent placement: Temporary relief of obstruction while planning definitive management

3. Percutaneous nephrostomy: Alternative approach for urinary diversion, especially if:

   • Infection is present
   • Ureteral access is difficult
   • Patient is too unstable for cystoscopy

4. Definitive treatment: Based on underlying cause

   • Ureteroscopy with stone extraction
   • Endoscopic tumor resection
   • Reconstruction for strictures or congenital anomalies

Risk Stratification for Hematuria

The American Urological Association recommends risk stratification for patients with hematuria 2:

• High-risk factors include:

  • Age (women ≥50 years, men ≥40 years)
  • Smoking history >30 pack-years
  • Gross hematuria
  • History of pelvic radiation
  • Occupational exposures (chemicals, dyes)

• Patients with high-risk factors require more urgent and comprehensive evaluation

Common Pitfalls to Avoid

1. Delaying urologic referral: Delays >9 months in evaluation of hematuria in patients with bladder cancer are associated with decreased survival 2

2. Assuming benign etiology: Even in young patients, significant hematuria with hydronephrosis warrants thorough evaluation

3. Inadequate imaging: While CT with contrast has been performed, additional studies may be needed to fully characterize the abnormality

4. Neglecting to assess both kidneys: Ensure that the contralateral kidney is functioning normally if intervention on the affected side is planned

5. Missing concomitant infection: Obstructive uropathy with infection (pyonephrosis) is a urologic emergency requiring immediate decompression

In conclusion, the patient with hydronephrosis, hydroureter, and hematuria on CT scan requires prompt urologic evaluation with cystoscopy and possible urinary tract decompression to prevent renal damage and identify the underlying cause.