Bilateral Hydronephrosis in Adults: To Do or Not To Do Percutaneous Nephrostomy

Transcription

1 Bilateral Hydronephrosis in Adults: To Do or Not To Do Percutaneous Nephrostomy Poster No.: C-0802 Congress: ECR 2014 Type: Educational Exhibit Authors: S.-H. You, D. J. Sung, N. Y. Han, B. J. Park, M. J. Kim, S. B. Cho; Seoul/KR Keywords: CT, Kidney, Education, Education and training DOI: /ecr2014/C-0802 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 35

2 Learning objectives This pictorial review reminds a practical concept for bilateral hydronephrosis according to its causes and level and provides appropriate treatment algorithm with imaging findings and illustrations. Background As we know, bilateral hydronephrosis should be treated to prevent progressive renal deterioration. Various conditions causing bilateral hydronephrosis (ex. bilateral ureteral stones, tumor invasions of bilateral ureters, etc.) require percutaneous nephrostomy (PCN). However, PCN is not the only way to resolve the bilateral hydronephrosis. Some conditions can be just managed by percutaneous suprapubic cystostomy (ex. bladder outlet obstruction including BPH, prostate cancer or urethral stricture), manual reduction (ex. cystocele) and indwelling Foley catheter (ex. neurogenic bladder). Findings and procedure details There are two types of the urinary tract obstruction according to the mechanism, mechanical obstruction and functional obstruction. Urinary tract obstruction could cause hydronephrosis. However, hydronephrosis is not always developing problem because we have two kidneys. Bilateral hydronephorosis and unilateral hydronephrosis with single kidney can cause acute renal failure or urinary sepsis. For this reason, nephrologist considers external urinary drainage, especially percutaneous nephrostomy (PCN), when meet the patient with bilateral hydronephrosis. However, it is not always the best treatment choice. The PCN has several complications such as hemorrhage and there are several other appropriate procedures to decompressing the urinary tract obstruction according to the 'causes' or 'level' of the obstruction. So we classify bilateral hydronephrosis according to the 'level' and 'causes' of obstruction, and suggest the appropriate procedures for resolving it with imaging appearances and illustrations. 1. The classification of the hydronephrosis according to the 'level' and 'causes' of obstruction (benchmark of the level: ureterovesical junction - upper/lower). 1) Mechanical Page 2 of 35

3 A-1) Upper urinary obstruction: usually unilateral a) Intrinsic: Stone, clot, tumor b) Extrinsic: Pregnancy (by enlarged uterus), tumor, retroperitoneal fibrosis A-2) Upper urinary obstruction: rarely bilateral a) Intrinsic : Bilateral stones b) Extrinsic : Tumor invasion in bilateral ureters B-1) Lower urinary obstruction: usually bilateral a) Tumor involvement of bilateral UVJs : Bladder cancer, prostatic cancer, cervical Cancer.. etc b) Bladder outlet obstruction : BPH, urethral stricture c) Cystocele, uterine prolapse 2) Functional: Usually bilateral A) Pregnancy : The effect of progesterone (Decreased peristalsis of the ureter) B) Neurogenic bladder (hypertonic) 2. Cases based treatment approaches : Learning with 10 interesting quiz!! Category1. Mechanical - upper urinary tract obstruction Quiz 1. Category 2. Mechanical - lower urinary tract obstruction Quiz 2-7. Category 3. Functional obstrution Quiz Images for this section: Page 3 of 35

4 Fig. 1: When meet the patient with bilateral hydronephrosis. However, it is not always the best treatment choice. The PCN has several complications such as hemorrhage and there are several other appropriate procedures to decompressing the urinary tract obstruction according to the 'causes' or 'level' of the obstruction. Page 4 of 35

5 Fig. 2: Category1. Mechanical - upper urinary tract obstruction Page 5 of 35

6 Fig. 3: Quiz 1) Which is the best next choice for this patient? 1. Bilateral PCN 2. Try to foley catheter insertion 3. Suprapubuc cystostomy 4. Tumor resection 5. Hormone therapy Answer) 1. Bilateral PCN Reason) Tumor involves bilateral UVJs. Page 6 of 35

7 Fig. 4: Category 2. Mechanical - lower urinary tract obstruction Page 7 of 35

8 Fig. 5: Quiz 2) Which is the best next choice for this patient? 1. Bilateral PCN 2. Try to foley catheter insertion 3. Suprapubuc cystostomy 4. Tumor resection 5. Hormone therapy Answer) 1. Bilateral PCN Reason) Tumor involves bilateral UVJs. Page 8 of 35

9 Fig. 6: Follow up images of the quiz 2. Page 9 of 35

10 Fig. 7: Quiz 3) Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Tumor resection 5. Hormone therapy Answer) 2. Indwelling foley catheter Reason) Tumor does not involve UVJ. Fig. 8: Follow up images of the quiz 3. Fig. 9: Brief review with illustration of the quiz 3. Page 10 of 35

11 Fig. 10: Summary of the quiz 3. Page 11 of 35

12 Fig. 11: Category 2. Mechanical - lower urinary tract obstruction Page 12 of 35

13 Fig. 12: Quiz 4) Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Tumor resection 5. Hormone therapy Answer) 2. Foley catheter insertion # Next step 5. Hormone therapy Reason) Bilateral hydronephrosis is caused by BPH Page 13 of 35

14 Fig. 13: Quiz 5) Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Tumor resection 5. Hormone therapy Answer) 2. Foley catheter insertion # Next step 5. Hormone therapy Reason) Bilateral hydronephrosis is caused by BPH Page 14 of 35

15 Fig. 14: Follow up images of the quiz 5. Page 15 of 35

16 Fig. 15: Brief review with illustration of the quiz 4 and 5. Page 16 of 35

17 Fig. 16: Brief review with illustration of the quiz 4 and 5. Page 17 of 35

18 Fig. 17: Quiz 6) Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Tumor resection 5. Hormone therapy Answer) 3. Suprapubuc cystostomy Page 18 of 35

19 Fig. 18: Brief review with illustration of the quiz 6. Page 19 of 35

20 Fig. 19: Category 2. Mechanical - lower urinary tract obstruction Page 20 of 35

21 Fig. 20: Quiz 7) Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Pessary insertion or operation 5. Medication Answer) 3. Suprapubuc cystostomy Page 21 of 35

22 Fig. 21: Brief review with illustration of the quiz 7. Page 22 of 35

23 Fig. 22: Category 3. Functional obstrution Page 23 of 35

24 Fig. 23: Quiz 8) Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Medication 5. Observation Answer) Observation Reason) It is a physiologic change during the pregnancy Page 24 of 35

25 Fig. 24: Brief review with illustrations of the quiz 8. Page 25 of 35

26 Fig. 25: Brief review with illustrations of the quiz 8. Page 26 of 35

27 Fig. 26: Brief review with illustrations of the quiz 8. Page 27 of 35

28 Fig. 27: Summary of the quiz 8. Page 28 of 35

29 Fig. 28: Category 3. Functional obstrution Page 29 of 35

30 Fig. 29: Quiz 9 Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Medication 5. Observation Answer) 2. Indwelling foley catheter Page 30 of 35

31 Fig. 30: Quiz 10) Which is the best next choice for this patient? 1. Bilateral PCN 2. Indwelling foley catheter 3. Suprapubuc cystostomy 4. Medication 5. Observation Answer) 3. Suprapubuc cystostomy Page 31 of 35

32 Fig. 31: Brief review with illustration of the quiz 10. Page 32 of 35

33 Fig. 32: Summary of the quiz 10. Page 33 of 35

34 Conclusion Most of the bilateral hydronephrosis are caused by obstruction below the UVJs or functional reason. So PCN is not the best choice in most of the case. It is important to consider the "level" and "cause" of the bilateral hydronephrosis and choice the best way (ex. Foley catheter insertion, suprapubic cystostomy,medication, operation and PCN) to decompress the bilateral hydronephrosis. Images for this section: Fig. 33: Image based appropriate treatment algorithm for bilateral hydronephrosis Page 34 of 35

35 Personal information Sung-Hye You, Deuk Jae Sung, Na Yeon Han, Beom Jin Park, Min Ju Kim, Sung Bum Cho Department of Radiology, Anam Hospital, Korea University, Seoul, South Korea References Black, L, et al, "An examination of treatment patterns and costs of care among patients with benign prostatic hyperplasia". The American journal of managed care 2006;12: S99-S110. JY Kang, et al., National-wide data on the treatment of BPH in Korea, Prostate Cancer and Prostatic Diseases 2011;14: Dan Leibovici, et al. Cystoprostatectomy for erective palliation of symptomatic bladder invasion by prostate cancer, the journal of urology 2005;174: Richard S. Irwin, James M. Rippe, Manual of Intensive Care Medicine, Lippincott Williams & Wilkins 2009, p Justin I. Friedlander, et al, Obstructive Uropathy from Locally Advanced and Metastatic Prostate Cancer: An Old Problem with New Therapies, JOURNAL OF ENDOUROLOGY 2012;26: Pais VM, et al, Campbell-Walsh Urology 2007;vol. 2. 9th ed. Philadelphia: Saunders Elsevier: pp Peake SL, Rowburgh HB, Le Planglois S. Ultrasonic assessment of hydronephrosis in pregnancy. Radiology 1983; 146: Biyani CS, Joyce AD. Urolithiasis in pregnancy I: pathophysiology, fetal considerations and diagnosis. BJU Int 2002; 89: Ashraf Thabet, MD, et al, Interventional Radiology in Pregnancy Complications: Indications, Technique, and Methods for Minimizing Radiation Exposure, RadioGraphics 2012; 32: Guidelines on neurogenic bladder, Korean Continence Society, S. Lewis, et al., Major complications after percutaneous Nephrostomy lessons from a department audit, Clinical Radiology 2004; 59: Klaus Armin Hausegger, et al., Percutaneous nephrostomy and antegrade ureteral stenting: technique-indication- complications, Eur Radiol 2006;16: Chad A. Grotegut, M.D., Ureteral Obstruction in Pregnancy, N Engl J Med 2004; 351:e14 Page 35 of 35