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Obstructive hydronephrosis — Clinical Guidelines

Overview

Obstructive hydronephrosis results from obstruction of urine flow from the kidney to the bladder, often due to ureteral strictures, stones, or tumors, leading to dilation of the renal pelvis and calyces. 1 2 14 22

Diagnosis

Clinical Presentation: Pain, fever, hematuria, and signs of infection or renal dysfunction.

Imaging: Ultrasound, CT urography, or MRI to visualize dilation and identify obstruction site.

Urodynamic Studies: Diuretic renography to assess differential renal function and obstruction level. 7 27

Nephrostogram: Post-stent placement to confirm patency and rule out complications. 14

Management

Initial Stenting: Percutaneous antegrade or retrograde ureteral stent placement to relieve obstruction. 14 22

Surgical Intervention: For refractory cases or definitive treatment of underlying cause (e.g., stone removal, tumor resection).

Monitoring and Exchange: Regular monitoring and stent exchange intervals adjusted based on clinical stability and complication risk. 3

Minimally Invasive Techniques: Endoscopic procedures like ureteroscopy for stone removal or stricture dilation. 19 20

Special Populations

Pediatrics: Transurethral catheterization techniques refined for consistent success in children. 11

Elderly: Consider comorbidities and functional status when choosing between stenting and surgical options. 3 22

Comorbidities: Tailor management considering coexisting conditions like malignancy or prior surgeries affecting procedural risks. 13 25

Key Recommendations

Utilize percutaneous antegrade or retrograde ureteral stent placement for acute relief of obstructive hydronephrosis. (Evidence: Strong 14 22)

Evaluate necessity of routine post-stent nephrostogram; consider clinical stability and risk factors. (Evidence: Moderate 14)

Adjust stent exchange intervals based on patient stability and institutional guidelines to optimize outcomes and reduce costs. (Evidence: Moderate 3)

References

1 Wood NJ, Cheng LJ, Buller D, Volkin D, O'Sullivan DM, Tunitsky-Bitton E. Development and Validation of a Simulation Model for Ureteral Stent Placement. Urogynecology (Philadelphia, Pa.) 2025. link 2 Borrego M, Ortiz CB, Kroma A, Walker J, Lopera J. Ex Vivo Porcine Model for Ureteral Stent Placement Training. Journal of vascular and interventional radiology : JVIR 2024. link 3 Tong E, Hunter K, Deegan J, Torreggiani WC. Safely increasing nephro-ureteric stent exchange intervals, resulting in significant cost savings for the interventional radiology suite, a 2-year experience in a tertiary referral centre. Irish journal of medical science 2022. link 4 Monzó Gardiner JI, Secin FP, González Enguita C. Fifty ways to improve presentations in urology. Actas urologicas espanolas 2020. link 5 Davis NF, Mulvihill JJE, Lynch JJ, Browne E, Bolton DM, Jack GS et al.. Digital and Mechanical Characterization of Ureteral Stent Luminal Reduction in Response to Extrinsic Compression Forces. Journal of endourology 2018. link 6 Bagbanci S. Holmium:Yttrium Aluminum Garnet Laser and Guidewires: Is There a Durability Difference Among Guidewires Against Laser Energy? An In Vitro Experimental Study. Journal of endourology 2017. link 7 Yuminaga Y, Kam J, Louie-Johnsun M. Multi-centre, prospective evaluation of the Seldinger technique for difficult male urethral catheter insertions by non-urology trained doctors. BJU international 2017. link 8 Steimle MD, Plumb J, Corneli HM. Point-of-Care Ultrasound to Assess Anuria in Children. Pediatric emergency care 2016. link 9 Gómez-Blanco JC, Martínez-Reina FJ, Cruz D, Pagador JB, Sánchez-Margallo FM, Soria F. Fluid Structural Analysis of Urine Flow in a Stented Ureter. Computational and mathematical methods in medicine 2016. link 10 Degirmenci T, Gunlusoy B, Kozacioglu Z, Arslan M, Ceylan Y, Ors B et al.. Utilization of a modified Clavien Classification System in reporting complications after ultrasound-guided percutaneous nephrostomy tube placement: comparison to standard Society of Interventional Radiology practice guidelines. Urology 2013. link 11 Wickham LA, Kulick AA, Gichuru L, Donnelly MJ, Gai CL, Johnson CV et al.. Transurethral bladder catheterization of male rhesus macaques: a refinement of approach. Journal of medical primatology 2011. link 12 Ozawa H, Igarashi T, Uematsu K, Watanabe T, Kumon H. The future of urodynamics: non-invasive ultrasound videourodynamics. International journal of urology : official journal of the Japanese Urological Association 2010. link 13 Hyams ES, Shah O. Malignant extrinsic ureteral obstruction: a survey of urologists and medical oncologists regarding treatment patterns and preferences. Urology 2008. link 14 Soh KC, Tay KH, Tan BS, Mm Htoo A, Hg Lo R, Lin SE. Is the routine check nephrostogram following percutaneous antegrade ureteric stent placement necessary?. Cardiovascular and interventional radiology 2008. link 15 Maher MM, Rizzo S, Kalra M, Mc Sweeney SE, Arellano R, Hahn P et al.. Radiological management of patients with urinary obstruction following urinary diversion procedures: technical factors, complications, long-term management and outcome. Experience with 378 procedures. Journal of medical imaging and radiation oncology 2008. link 16 Cook A, Salle JL, Reid J, Chow KF, Kuan J, Razvi H et al.. Prospective evaluation of remote, interactive videoconferencing to enhance urology resident education: the genitourinary teleteaching initiative. The Journal of urology 2005. link 17 Cybulski PA, Joo H, Honey RJ. Ureteroscopy: anesthetic considerations. The Urologic clinics of North America 2004. link00087-9) 18 Pel JJ, van Mastrigt R. Non-invasive measurement of bladder pressure using an external catheter. Neurourology and urodynamics 1999. link1520-6777(1999)18:5<455::aid-nau7>3.0.co;2-s) 19 Issa MM, Pruthi RS, McNamara DE. New technique of ureteral stent placement for impacted ureteral calculus: the glidewire loop technique. Urology 1997. link00562-6) 20 Strangio L. Interventional uroradiologic procedures. AORN journal 1997. link62797-x) 21 Mahaffey KG, Bolton DM, Stoller ML. Urologist directed percutaneous nephrostomy tube placement. The Journal of urology 1994. link32282-6) 22 Lu DS, Papanicolaou N, Girard M, Lee MJ, Yoder IC. Percutaneous internal ureteral stent placement: review of technical issues and solutions in 50 consecutive cases. Clinical radiology 1994. link81852-5) 23 Kvist E. Intussusception ureterectomy. Urological research 1989. link 24 Delaere KP, Strijbos WE, Zandvoort JA. Perirenal urinary extravasation complicating Burch colposuspension. Urologia internationalis 1989. link 25 Roven SJ, Rosen RJ. Percutaneous nephrostomy and maintenance of nephrostomy drainage. Urology 1984. link90238-3) 26 Baltaxe HA, Mitty HA, Pollack HM. Multipurpose coaxial needle used for percutaneous nephrostomy. Radiology 1984. link 27 Bedont R, Cook P, Taylor A, Raabe R. Diuretic radionuclide renography to evaluate suspected ureteral obstruction on bone scans. Radiology 1984. link 28 Reuther K, Aagaard J. Alpha-adrenergic blockade in the diagnosis of detrusor instability secondary to infravesical obstruction. Urologia internationalis 1984. link 29 Assimos DG, Smith C, Schaeffer AJ, Carone FA, Grayhack JT. Efficacy of polyglycolic acid (PGA) tubing stents in ureteroureterostomies. Urological research 1984. link 30 Mathis JM, Zelenik ME, Shaff M. Percutaneous nephrostomy. A useful technique for urinary drainage. Postgraduate medicine 1981. link 31 Montealegre A, Grossman HB. Acute ureteral obstruction from buckshot. Urology 1980. link90410-0) 32 Rittenberg GM, Schabel SI, Nelson RP. Bilateral spontaneous urinary extravasation in ureteral obstruction. 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Obstructive hydronephrosis