Surgical or Conservative Treatment of Congenital Hydronephrosis

Introduction:

Congenital hydronephrosis is a pathology characterized by an obstruction to the kidney causing swelling or dilatation of the kidneys. Its treatment depends on various factors like the cause of the disease, the severity of the disease, and the symptoms. It can vary among individuals as each person has a unique set of characteristics. Both conservative and surgical approaches are selected on an individual basis and quickly begun. Hydronephrosis simply means there is an enlarged capacity of the renal collecting system. The dilatation of the urinary tract can occur due to various reasons including vesicoureteral reflux, diuretic effects, and resolution of a developmental anomaly through spontaneous surgical means.

What Is Hydronephrosis and How Is It Managed?

Hydronephrosis is a pathological condition in which the renal pelvis and renal calyces become dilated due to the reflux or stagnation of urine. It occurs in around 1 to 5 % of pregnancies and the most common form of hydronephrosis is ureteropelvic junction obstruction (UPJO), with a prevalence rate of 10 to 30 %. Pathogenesis of congenital hydronephrosis involves urinary tract abnormality leading to renal pelvis dilatation. This obstruction can be anywhere such as the ureter, ureteropelvic junction, and ureterovesical junction. The cause of this disease can be due to anatomical abnormalities, blockage in the urinary tract, backflow of urine from the bladder to kidneys (vesicoureteral reflux), and other structural abnormalities.

How Is Congenital Hydronephrosis Diagnosed?

Congenital nephrosis is diagnosed appropriately with the help of the following approaches:

1. Renal Ultrasound: This is a painless procedure and utilizes sound waves to produce an image of the kidney. It is the most frequently employed method to monitor hydronephrosis due to its non-invasive nature. It is typically performed every three to six months.

2. Nuclear Renal Scan: This is one of the most efficient diagnostic tests carried out for determining the degree of obstruction. However, it necessitates the insertion of an IV (intravenous) catheter and a bladder catheter. A nuclear isotope is injected into the bloodstream, and then a specialized external camera will help in tracking the movement of the isotope in the kidneys and bladder. Though with the help of utilizing advanced technology, this test is not infallible and cannot always differentiate between kidneys that will spontaneously correct themselves. The radiation exposures associated with this are actually lower than that of a similar X-ray study. A nuclear scan is typically performed every 4 to 12 months and provides information about kidney function and urine flow (obstruction).

What Is the Conservative Approach to Treating Congenital Hydronephrosis?

The conservative approach is focused on monitoring the disease and treating associated symptoms in a stepwise manner. In milder cases of congenital hydronephrosis, surgery is never recommended and it can be managed non-operatively with punctilious follow-ups with the healthcare professional. The following are done for conservative management:

1. Watchful Waiting: Close monitoring of the symptoms is important. In cases of mild hydronephrosis, a conservative approach includes regular follow-up with the healthcare professional. This step is crucial to prevent the disease from worsening.

2. Antibiotics: When a urinary tract infection is associated with this hydronephrosis, antibiotics are administered to resolve the infection and prevent the recurrence. This will help alleviate symptoms and also reduce the risk of complications.

3. Diuretics: In certain instances of mild hydronephrosis, diuretics are prescribed for the management of urinary flow and reduction of kidney swelling. This approach is beneficial in managing this condition and improving overall urinary system function.

What Are the Indications for Surgery?

Determining the need for surgery is complex and if left untreated also it can lead to various issues. The significant outcome of congenital hydronephrosis includes a decline in kidney function, frequent infection, pain, and the formation of stones. It is decided by keeping in consideration the factors like kidney function, the extent of obstruction, level of dilation, and severity of symptoms. Some patients may experience spontaneous resolution in milder cases. However certain clear indication for undergoing surgery includes:

• Persistent and severe dilatation.

• Significant obstruction in imaging studies.

• Declining in kidney function.

What Is the Surgical Approach to Treating Congenital Hydronephrosis?

Debate still exists when deciding the right treatment approach for congenital hydronephrosis. Scientists and research papers suggest surgical management in cases of congenital hydronephrosis with longer drainage time, differential renal function less than 40 %, recurrent urinary infections, and those having grade 4 hydronephrosis. If a conservative approach to the management of congenital hydronephrosis fails, a surgical approach is carried out. Surgical management includes the following. Based on the underlying cause, additional surgical procedures may be required. These include pyeloplasty, ureteral implantation, nephrectomy, and other interventions that are tailored to specific conditions.

• Pyeloplasty: Pyeloplasty is a surgical procedure that is aimed at addressing congenital hydronephrosis caused due to obstruction or abnormality in the junction where the renal pelvis connects to the ureter. Pyeloplasty is commonly performed and it helps correct the abnormality thereby restoring normal urine flow.

• Ureteral Implantation: It is a surgical procedure that is performed in patients with hydronephrosis used to redirect or reposition the ureter for improving urine flow and alleviating the obstruction in the kidneys.

• Nephrectomy: A nephrectomy is a surgical approach involving the removal of the affected kidney and the associated obstructions. This is done in cases where the kidney is non-functioning or extremely damaged. This extremely damaged kidney can affect the overall health of the individual. Therefore, a nephrectomy is performed. Nephrectomy can be done in various methods including laparoscopic or robotic surgery based on the expertise and choice of the surgeon. Post this surgery, the remaining kidney takes full responsibility for excreting and filtering waste products from the body. It is also important to note that the remaining unaffected kidney can function well and the individual can lead a healthy life, as the compensation is done well for the removed kidney loss.

Conclusion:

It is crucial to choose the right treatment approach for congenital hydronephrosis. This is decided by the specialist such as an urologist or nephrologist after considering factors like the patient's overall health, severity of disease, and presence of symptoms. The risks and benefits of surgery should be discussed with patients out-and-out.