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Obstructive Hydroureteronephrosis

M Stephen Ledbetter, MD
Donald DiSalvo, MD

July 24, 1996

Presentation

A 41-year-old woman presented with right flank pain and hematuria.

Imaging Findings

Abdominal ultrasonography

Sonographic images show a dilated right renal collecting system (black arrows) with a small perinephric urinoma (white arrow). Additionally, a shadowing hyperechoic structure (arrow) in the distal right ureter is visible posterior to the uterus. Ultrasound of the bladder demonstrates a left ureteral jet (arrow) which was not demonstrable on the right. Measurements of resistive indices are upper normal for the right, at 0.67, and normal for the left, at 0.52. The difference in resistive indices, 0.15, is consistent with an acutely obstructive unilateral process.

Differential Diagnosis

The differential diagnosis of hydroureteronephrosis in a normal size kidney is essentially between obstruction (such as from a ureteral calculus) and dilatation (such as from vesicoureteral reflux). Polar atrophy is most commonly seen in longstanding vesicoureteral reflux (not seen here). Multiple peripelvic cysts have a sonographic appearance that can mimic dilated calices.

Diagnosis

Obstructing stone in the distal right ureter resulting in hydroureteronephrosis

Discussion

Unilateral hydroureteronephrosis may be the result of obstruction of the collecting system, most commonly at the ureteropelvic junction (UPJ), the ureterovesicular junction, or the pelvic brim. Differentiating acute obstruction from vesicoureteral reflux is aided by doppler measurements of blood flow, called resistive indices. Resistive indices above 0.70, or a bilateral difference of 0.10 or more, are consistent with an acute obstruction. In the female patient with a strong clinical suspicion of obstruction, and in whom conventional transabdominal sonography fails to show the point of obstruction, transvaginal imaging of the distal ureter may aid in the diagnosis, as is demonstrated in this companion case which shows a caculus at the ureterovesicular junction (arrow).

References

1. Sarti DA, Sample WF. Diagnostic ultrasound: text and cases. Boston: GK Hall Medical Publishing, 1980: 318.

2. Krebs CA, Giyanani VL, Eisenberg RL. Ultrasound atlas of disease processes. Norwalk, CT: Appleton & Lange, 1993: 138-139.

3. Brkljacic B, Drinkovic I, Sabljar-Matovinovic M, et al. Intrarenal duplex doppler sonographic evaluation of unilateral native kidney obstruction. Journal of Ultrasound in Medicine 1994; 13:197-204.

4. Laing FC, Benson CB, et al. Distal ureteral calculi: Detection with vaginal US. Genitourinary Radiology 1992; 2: 545-548.

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