What is the treatment for hydroureter?

Treatment of Hydroureter

The treatment of hydroureter depends critically on the underlying cause and clinical presentation: urgent decompression via percutaneous nephrostomy (PCN) or retrograde ureteral stenting is mandatory for obstructed systems with sepsis or anuria, while conservative management with close monitoring is appropriate for mild, asymptomatic cases. 1

Acute/Emergency Management

Sepsis or Anuria with Obstruction

• Immediate urinary decompression is lifesaving and strongly recommended via either PCN or retrograde ureteral stenting 1
• Urine culture must be obtained before and after decompression for antibiogram-guided antibiotic therapy 1
• Antibiotics should be administered immediately, with regimen adjustment based on culture results 1
• Definitive stone or obstruction treatment should be delayed until sepsis resolves 1
• Third-generation cephalosporins (ceftazidime) demonstrate superior clinical and microbiological cure rates compared to fluoroquinolones 1

Choice Between PCN vs Retrograde Stenting

• Retrograde ureteral stenting is usually appropriate as first-line for obstructing stones with infection 1
• PCN is preferred when:
  • Patient is high-risk for anesthesia 1
  • Pyonephrosis is present (larger tube decompression needed) 1
  • Retrograde access fails 1
  • Extrinsic ureteral obstruction exists (lower urosepsis risk with PCN) 1

Obstructive Stone Disease

Without Sepsis

• Medical expulsive therapy with α-blockers is efficacious for ureteral stones >5 mm amenable to conservative management 1
• NSAIDs (diclofenac, ibuprofen, metamizole) are first-line for renal colic pain 1
• Opioids are second-choice analgesics if NSAIDs contraindicated 1

With Obstruction

• Retrograde double-J ureteral stenting prior to definitive ureteroscopic extraction is effective and safe even with sepsis 1
• Extracorporeal shock-wave lithotripsy combined with retrograde stenting shows superior stone eradication compared to PCN alone 1

Pediatric Hydroureter Management

Mild Renal Pelvis Dilatation

• No immediate intervention required for isolated mild dilatation (<1 cm) 2
• Ultrasound follow-up in 1-6 months is appropriate next step 2
• Continue monitoring every 6-12 months if stable 2
• At least one ultrasound every 2 years to monitor for "flow uropathy" 2

Clinically Significant Hydroureter (≥7 mm)

• Ureteral diameter ≥7 mm identifies high-risk patients for UTI who benefit from continuous antibiotic prophylaxis (CAP) 3
• CAP provides significant protection against UTI (50% risk reduction) 3
• Patients with hydroureter <7 mm without reflux may be managed more conservatively 3
• VCUG is not routinely indicated for isolated mild dilatation unless bilateral high-grade hydronephrosis, duplex kidneys, ureterocele, abnormal bladder, or febrile UTI history present 2

Indications for Urology Referral

• Evidence of obstruction on imaging 2
• Decreasing differential renal function 2
• Development of obstructive symptoms 2
• Renal parenchymal thinning 2

Special Populations

Pregnant Patients (≥20 weeks)

• Both retrograde ureteral stenting and PCN are usually appropriate for hydroureter with infection 1
• These represent equivalent alternatives for managing obstruction with sepsis 1

Malignancy-Related Obstruction

• Retrograde stenting, PCN, or percutaneous antegrade stenting are all appropriate options 1
• Choice depends on local invasion extent and patient performance status 1

Post-Surgical Ureteral Injury

• PCN decompression as primary management decreases reoperation need and morbidity 1
• Provides access for definitive treatment of strictures/leaks, obviating repeated surgery 1
• 75% of post-cesarean ureteral injuries successfully managed with stenting ± dilatation 1

Congenital Nephrogenic Diabetes Insipidus

Medical Management

• Hydroureteronephrosis occurs in 34% of NDI patients 1
• Thiazide diuretics (hydrochlorothiazide 25 mg once/twice daily) reduce polyuria 1
• Salt restriction potentiates diuretic efficacy 1
• COX inhibitors (celecoxib preferred) enhance collecting duct water reabsorption 1
• Discontinue COX inhibitors at age ≥18 years due to nephrotoxicity concerns 1

Monitoring

• Ultrasound of urinary tract every 2 years minimum to detect hydronephrosis, bladder wall hypertrophy, and post-void residual 1
• Repeated dilatation can cause permanent urinary tract/kidney damage 1

Common Pitfalls

• Do not delay decompression in septic patients—this is a medical emergency requiring immediate intervention 1
• Avoid assuming all hydroureter requires intervention—mild pediatric cases often resolve spontaneously 2, 3
• Do not use pethidine for pain control—other opioids have lower vomiting rates 1
• Recognize that internalized double-J stents alone quickly occlude in ileal loops due to mucus—use transileal retrograde nephroureteral catheters instead 1
• In non-refluxing hydroureter ≥7 mm, antibiotic prophylaxis significantly reduces UTI risk even without vesicoureteral reflux 3