What is the treatment for bilateral hydronephrosis?

Treatment for Bilateral Hydronephrosis

The treatment for bilateral hydronephrosis must be directed at the underlying cause and typically requires urinary tract decompression through percutaneous nephrostomy (PCN) or retrograde ureteral stenting, followed by definitive management of the obstruction. 1

Diagnostic Evaluation

• Initial evaluation should include assessment of renal function (creatinine, BUN), urinalysis for infection, and imaging to determine the cause and severity of obstruction 1
• CT urography provides comprehensive evaluation of the genitourinary tract with both morphological and functional information for identifying the cause of bilateral hydronephrosis 1
• Diuretic renography with MAG3 is the standard for confirming functional obstruction and differentiating true obstruction from non-obstructive dilation 1
• Ultrasound monitoring is recommended at least once every 2 years in patients with chronic hydronephrosis to assess for progression 1

Treatment Algorithm Based on Etiology

Acute Obstructive Hydronephrosis

• Urgent decompression is required when bilateral hydronephrosis is accompanied by:

  • Acute kidney injury
  • Infection/sepsis
  • Intractable pain 1

• Decompression options:

  1. Percutaneous nephrostomy (PCN) - preferred in cases of:

     • Sepsis
     • Failed retrograde stenting
     • Complete obstruction 1

  2. Retrograde ureteral stenting - preferred in:

     • Stable patients
     • When etiology allows for retrograde access 1

Specific Etiologies

• Urolithiasis: Retrograde ureteral stenting is usually appropriate, followed by definitive stone management 1

• Malignant obstruction: PCN or retrograde stenting based on technical feasibility, with PCN having higher success rates in cases of extrinsic compression or long strictures 1

• Pregnancy-related hydronephrosis:

  • Conservative management for physiologic hydronephrosis (70-90% of pregnancies) 1
  • Decompression with retrograde stenting or PCN for symptomatic cases with infection 1
  • Definitive treatment typically delayed until after delivery 1

• Post-surgical urinary leak: PCN or retrograde stenting to divert urine and allow healing 1

• Retroperitoneal fibrosis: Bilateral ureteral stent placement with potential long-term stenting or surgical ureterolysis 2

• Ascites-induced hydronephrosis: Large-volume paracentesis can resolve hydronephrosis by relieving external pressure 3

Special Considerations

• In neonatal bilateral hydronephrosis, initial nonoperative observation is often appropriate, as 78% of cases improve spontaneously within 2 years 4

• PCN technical success approaches 100% in dilated collecting systems and 80-90% in non-dilated systems 1

• For urinary diversions (e.g., after cystectomy), PCN followed by delayed surgery is usually appropriate when hydronephrosis develops 1

Complications to Monitor

• Acute kidney injury can develop rapidly with bilateral obstruction, requiring prompt intervention 1

• Risk of infection increases with prolonged obstruction 1

• Permanent nephron loss can occur if obstruction is not corrected in a timely manner 1

• PCN placement carries risks of bleeding, infection, and catheter dislodgement 5

Follow-up Management

• Regular monitoring of renal function and imaging follow-up are essential 1

• Definitive correction of the underlying cause should follow initial decompression 1

• In cases of malignant obstruction, prognosis and quality of life considerations should guide management decisions 1