Stone Surgery with Hydronephrosis

Risk Factors

Factors worsening hydronephrosis:

• Delayed presentation after stone obstruction
• Large stone burden causing complete obstruction
• Anatomical obstruction at ureteropelvic junction
• Pre-existing chronic kidney disease
• Concurrent urinary tract infection

Who is at Risk

Patients with large obstructing stones who have delayed seeking treatment, those with pre-existing kidney disease, and patients with anatomical abnormalities predisposing to obstruction are most at risk for severe hydronephrosis.

Diagnosis

Assessment includes:

• Urgent renal ultrasound to assess degree of hydronephrosis
• Non-contrast CT KUB for stone location and size
• Serum creatinine and electrolytes urgently
• Urine culture to exclude pyonephrosis
• Isotope renogram after decompression to assess functional recovery
• Follow-up CT urogram for anatomy and drainage assessment

Treatment Options

Immediate nephrostomy tube or ureteral stent placement decompresses the kidney and halts further renal damage. Definitive stone treatment is scheduled 2 to 4 weeks later after renal function recovery. PCNL via the nephrostomy tract is the most efficient definitive approach.

The Procedure

Management of stone with hydronephrosis involves:

• Urgent nephrostomy placement under ultrasound or fluoroscopic guidance
• Antibiotic cover for infection prevention or treatment
• Nephrostomy drainage for 2 to 4 weeks to allow renal recovery
• Isotope scan to assess post-decompression renal function
• PCNL via established nephrostomy tract for stone clearance
• Drainage tube maintained until stone-free status confirmed
• Staged approach for residual fragments if required

After the Surgery

Post-operative care includes:

• Renal function tests every 48 hours post-decompression
• Nephrostomy tube output monitoring and irrigation
• CT KUB after stone clearance to confirm stone-free status
• Gradual clamping trial before nephrostomy removal
• Nephrology review for renal function recovery assessment
• Long-term dietary and metabolic stone prevention program

Possible Complications of This Procedure

Potential complications include:

• Irreversible renal damage if decompression is delayed
• Post-decompression diuresis requiring IV fluid management
• Sepsis from infected obstructed kidney (pyonephrosis)
• Bleeding from nephrostomy insertion or PCNL
• Residual stones requiring additional treatment sessions
• Ureteral stricture from prolonged stone impaction