|Year : 2004 | Volume
| Issue : 2 | Page : 118-122
Giant hydronephrosis: What is the ideal treatment?
Shailesh A Shah, Prakash Ranka, Sharad Dodiya, Rajesh Jain, Gaurang Kadam
Department of Urology, Institute of Kidney Diseases and Research Centre and Institute of Transplantation Sciences, BJ Medical College & Civil Hospital Campus, Asarwa, Ahmedabad, India
Shailesh A Shah
Kidneyline Health Care, 1st Floor Harikrupa Towers, Near Govt. Ladies Hostel, Behind Gujarat College, Ellisbridge, Ahmedabad - 380 006
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : To formulate a strategic approach for the treatment of giant hydronephrosis based upon anatomical and functional status of renal units in the individual patient.
Methods : We have treated ten cases of giant hydronephrosis between November 1997 and December 2002. Age of the patients was in the range of 14 to 42 years. Seven were males and 3 were females. IVU revealed non-visualized unit of the affected side in 9 patients. One patient had bilateral hydronephrosis with azotemia. Percutaneous nephrostomy was done in all patients as a primary procedure. The quantity of urine drained instantaneously was between 1.2 litres to 2.5 litres. Antegrade study and creatinine clearance of the affected unit was done in all. Four patients were subjected to nephrectomy. Two patients underwent reduction pyeloplasty with nephropexy and 1 patient underwent primary calycoureterostomy. In two patients primary Boari flap calycovesicostomy was performed and in one patient with obstructed megaureter ureteroneocystostomy with tapering was done.
Results : Two patients, in whom Boariflap ealycovesicostomy was done, have refluxing units. They have been advised double voiding. Follow-up IVU, in 6 patients who underwent reconstructive procedure, demonstrated reasonable function and optimal drainage. Follow-up range is 4 months to 5 years.
Conclusions: In very poorly fimctioning unit with gross infection nephrectomy is the procedure of choice. In salvageable unit, anatomical configuration should dictate the type of reconstructive procedure. In a moderately dilated extra renal system, reduction pyeloplasty with nephropexy is a reasonable option. The entirely intrarenal dilated collecting system is an ideal situation for calycoureterostomy. In patients with enormous calyceal dilatation Boari flap; cahvcovesicostomy ensures wide, patent, dependent drainage.
Keywords: Giant hydronephrosis, pelviureteral junction obstruction, nephropexy, nephrectomy.
|How to cite this article:|
Shah SA, Ranka P, Dodiya S, Jain R, Kadam G. Giant hydronephrosis: What is the ideal treatment?. Indian J Urol 2004;20:118-22
| Introduction|| |
The presence of over 1000 ml of urine in a hydronephrotic sac in an adult is usually categorised as giant hydronephrosis. Yang et al (1958)  opined that the term giant hydronephrosis should be used only when the contents of the sac equalled to average daily urine output for that age. Giant hydronephrosis has also been defined as kidney that occupies a hemiabdomen, which meets or crosses the midline and which is at least 5 vertebrae in length.  Congenital ureteropelvic junction (UPJ) obstruction is the commonest cause of giant hydronephrosis in children and adults. Occasionally, it occurs as a result of ureterovesical junction obstruction.  Other causes include obstructive megaureter, ureteric atresia and obstructive ectopic ureter with or without a duplex system. Kruger (1993)  reported a case of giant hydronephrosis caused by an impacted ureteric stone on the right side and a blind-ending ureteric bud on the opposite side. We report ten cases of giant hydronephrosis. Our purpose is to discuss treatment and formulate management strategy in these cases based upon etiology, anatomical configuration and functionalstatus of renal units in the individual patient.
| Patients and Methods|| |
We have treated 10 cases of giant hydronephrosis in our institute between November 1997 and December 2002. Age of the patients was in the range of 14 to 42 years (mean age - 28 years). Seven patients were males and 3 were females. The common clinical presentation was flank pain and/or abdominal lump. Four patients had associated fever with chills. One patient presented with azotemia. On clinical examination a cystic smooth lump was found occupying nearly a herniabdomen. In 1 patient, the lump was crossing the midline and was mistaken for ascites by the family physician. Ultrasonography revealed bilateral massive hydronephrosis in 1 patient and normal contralateral unit in 9 patients. Serum creatinine was normal in 9 patients. One patient with bilateral giant hydronephrosis was in renal failure with serum creatinine 14 mg%. He was dialyzed before diversion. Intravenous urogram (IVU) in 9 patients revealed non-visualized unit on affected side. Percutaneous nephrostomy was done as a primary procedure in all patients. The quantity of urine drained instantaneously was between 1.2 to 2.5 litres. One patient had infected hydronephrosis which resolved following nephrostomy and antibiotics. Four patients had pyonephrosis with persistent turbid urine of small quantity (50 to 100 ml/24 hours) for 3 weeks. These 4 patients were subjected to simple nephrectomy. Our treatment policy was based upon a strategic approach [Figure - 1]. In 6 patients, urine was clear with daily nephrostomy output between 500 to 1500 ml and creatinine clearance in the range of 20 to 60 ml/min. In I patient, plain X-ray KUB revealed a calculus 1.5 cm x 1.5 cm in the lower ureter and nephrostogram revealed obstructed megaureter. This patient underwent ureterolithotomy, tapering of ureter and extravesical ureteric reimplantation. Antegrade study revealed UPJ obstruction in 5 patients with variable configuration of pelvicalyceal system. Two of them were subjected to reduction pyeloplasty with nephropexy. Primary calycoureterostomy was done in 1 patient. Two patients, including one with bilateral giant hydronephrosis, underwent Boari flap calycovesicostomy.
| Results|| |
Four patients who underwent simple nephrectomy had smooth postoperative recovery. One patient who underwent ureteric reimplantation had delayed wound healing and required secondary closure. Postoperative nephrostogram performed after 5 to 7 days showed no extravasation in any case with good drainage. Nephrostomy tube was removed after clamping for 24 hours. Double J stent was removed after 4 to 6 weeks. Follow up IVU, one week after stent removal, demonstrated good function and drainage in 5 patients. Voiding cystourethrogram (VCUG) demonstrated refluxing units in 2 patients who underwent Boari flap calycovesicostomy but no post-void residual urine after double voiding. One patient, who presented with azotemia and underwent bilateral Boari flap calycovesicostomy, has mild chronic renal insufficiency with nadir serum creatinine level 2.5 mg%. Follow-up was in the range of 4 months to 5 years (mean = 32 months).
| Discussion|| |
The earliest and the largest hydronephrotic sac, containing 115 litres of fluid, was recorded by Glass (1746)  in an autopsy report on a 22 year old woman. Tombari et al (1968)  reported the second largest case of giant hydronephrosis (52 litres) and reviewed 61 cases in the literature. They found out that out of 61 cases, an erroneous diagnosis was made in 33 cases (54%) and paracentesis was done in 12 cases (20%) because of the initial diagnosis of ascites. In the present series of 10 cases, initial diagnosis of ascites was made in 1 patient (10%). The decline in incidence of erroneous diagnosis is perhaps attributable to widespread availability of expert sonologists. Since this is a slowly progressive disease, a large abdominal mass or distended abdomen maybe the only sign.  Occasionally, patients present with flank pain, hematuria or recurrent urinary tract infection. Uremia may occur in gross bilateral disease.  In the present series, 1 patient presented with azotemia.
Our experience is that all patients with giant hydronephrosis do not have similar anatomical configuration and functional status of renal units, and therefore treatment has to be individualized in every patient. We have formulated a strategic approach for treatment of giant hydronephrosis [Figure - 1]. We favour percutaneous nephrostomy if patient is febrile and/or serum creatinine is elevated or IVU shows non-visualized unit or pelvicalyceal system is not well delineated. Further, based upon overall functional status, ablation of unit or reconstructive surgery is planned. The type of reconstruction is individualized as per anatomical configuration demonstrated on antegrade study or IVU.
In our series, two patients who had grossly dilated extrarenal pelvis, underwent reduction pyeloplasty with nephropexy. Hemal et al (1998)  studied the role of nephroplication and nephropexy as an adjunct to primary surgery in 20 renal units of 16 patients with giant hydronephrosis. Nephropexy reduces stasis and improves dependent drainage by tilting the pelvicalyceal system laterally and bringing it more in line with the upper ureter. We performed nephropexy alone as an adjunctive procedure because nephroplication per se reduces calyceal size, so in massive calyceal dilatation we resorted to either primary calycoureterostomy or Boari flap calycovesicostomy.
Levitt et al (1981),  performed 15 calycoureterostomies as the primary treatment for UPJ obstruction when the dilated lower pole calyx was actually the most dependent portion in a dilated intrarenal collecting system. They pointed out that in cases of massive calyceal dilatation, peristaltic activity in the collecting system is seriously compromised and urinary drainage from the pelvis into the upper ureter is essentially by gravity. Thus, entirely intrarenal dilated collecting system is an ideal situation for calycoureterostomy. They, however, cautioned against attempting this procedure in cases when the lower pole parenchymal cap is thick and well preserved. In the present series, in one patient, in whom the dilated lower calyx was the most dependent portion, primary calycoureterostomy provided effective dependent drainage. Ansari et al (1999)  reported dual drainage to salvage giant hydronephrosis, in a patient with right UPJ obstruction and a blindending left ureter. They performed dismembered pyeloplasty plus ureterocalycostomy with left blind-ending ureter to provide supplementary dependent drainage.
Calycocystostomy  and Boari flap calycovesicostomy  have been recommended in cases with massive calyceal dilatation and severely compromised peristalsis in the collecting system. Mandal et al (1990)  reported Boari flap calycovesicostomy in 2 patients with giant hydronephrosis in a solitary kidney. They performed this operation as a primary procedure in 1 patient and as a salvage procedure in another patient after failed pyeloplasty. They concluded that Boari flap calycovesicostomy ensures wide patent dependent drainage without any risk of anastomotic stricture. We performed primary Boari flap calycovesicostomy in 2 patients in whom the lower pole of the kidney was found to be reaching almost to the pelvic brim and the cortical tissue appeared thin. One of these patients had bilateral giant hydronephrosis.
A disadvantage of calycovesicostomy is vesicocalyceal reflux. But the broad base to the Boari flap bears the brunt of the increased intravesical pressure and protects the kidney from the deleterious effects of reflux.  No glomerular or tubular functional and histological abnormalities have been noted in an experimental study using a canine model  or in renal allotransplant recipients with vesico calycostomy. ,
In 1999, Hemal et al  reported 18 laparoscopic nephrectomy for giant hydronephrosis. They performed initial 6 cases via transperitoneal approach. Once they attained proficiency in retroperitoneoscopic surgery for smaller kidneys they used retroperitoneal approach for next 12 cases. They pointed out that initial operator disorientation occurs because of the large hydronephrotic sac occupying the retroperitoneum, which obscures the standard landmarks for surgery. In the present series, we performed open nephrectomy in 4 cases because so far we are doing retroperitoneoscopic surgery for small kidneys only. We, however, endorse the view that laparoscopic nephrectomy is a better alternative to open surgery if expertise is available.
In the present series, the recovery of renal function and effective drainage following different reconstructive procedures in different patients substantiate the strategy that anatomical configuration should dictate the type of operation in individual patients.
| Conclusions|| |
Giant hydronephrosis is an uncommon clinical entity. We have reported 10 cases of giant hydronephrosis and have formulated a strategic approach to treat this subset of patients. In very poorly functioning unit with gross infection, nephrectomy is the procedure of choice. If unit is salvageable then based upon the anatomical configuration, the type of reconstructive procedure should be selected. Ureteral tapering with reimplantation, dismembered pyeloplasty with nephropexy, primary calycoureterostomy, primary Boari flap calycovesicostomy provide effective dependent drainage in relevant cases.
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[Figure - 1]