Pediatric Hydronephrosis: Causes and Treatment Options

Pediatric kidneys

Good afternoon.
My daughter was diagnosed with congenital hydronephrosis at the age of 11.
Her left kidney had already become swollen due to fluid accumulation, causing severe pain that made her vomit.
She required surgery, and the doctor said it would be a minor procedure to remove the obstructed portion.
However, after the surgery, the kidney continued to have fluid accumulation, leading to another surgery where a double-J stent was placed to assist with urine drainage.
We were advised to monitor her for six months, but less than four months later, she had to go to the emergency room again due to hydronephrosis.
This resulted in another surgery to replace the stent.
Unfortunately, every time the stent was in place for 3-4 months, she experienced severe pain and vomiting, requiring emergency care.
The hospital could only provide pain relief while waiting for the doctor to schedule the stent replacement.
This process has repeated five times over the span of three years, and my daughter has been suffering from this condition.
Each time she experiences pain from the fluid accumulation, she is unable to attend school for a week, and we frequently visit the hospital.
I would like to know if there are any other methods for draining the kidney besides pain management and stenting.
Are there alternative treatment options or other potential causes for hydronephrosis? Thank you.

Tu Mama, 50~59 year old female. Ask Date: 2020/07/23

Dr. Zhong Ruixian reply Pediatrics

Dear Mother Tu,
If renal hydronephrosis causes symptoms of a certain severity, it requires intervention.
The treatment depends on the location and degree of obstruction:
1.
If the child has congenital ureteral stenosis, a double-J ureteral stent can temporarily replace the ureter.
2.
If the child has vesicoureteral reflux (which can be confirmed through a VCUG - voiding cystourethrogram), the cause may be structural abnormalities at the junction of the bladder and ureter (such as bladder-ureteral stenosis or abnormal valve closure), leading to reflux.
The treatment options include surgical intervention at the site of the obstruction, as well as less invasive treatments such as the injection of hyaluronic acid.
This aspect falls under pediatric surgical expertise, and I know that Taichung Veterans General Hospital's pediatric surgery department is involved in this type of treatment.
You may consult them for more information.
Wishing you good health,
Zhong Ruixian

Reply Date: 2020/07/23

More Info

Hydronephrosis in children is a condition characterized by the swelling of a kidney due to a build-up of urine. This can occur when there is an obstruction in the urinary tract that prevents urine from draining properly from the kidney to the bladder. Understanding the causes and treatment options for pediatric hydronephrosis is crucial, especially in the context of your daughter's ongoing struggles with this condition.

Causes of Pediatric Hydronephrosis
Hydronephrosis can be caused by several factors, including:
1. Congenital Obstructions: These are structural abnormalities present at birth, such as ureteropelvic junction obstruction (UPJ), where the connection between the kidney and ureter is narrowed, preventing normal urine flow.

2. Urinary Tract Infections (UTIs): Recurrent UTIs can lead to scarring and obstruction in the urinary tract.

3. Vesicoureteral Reflux (VUR): This condition occurs when urine flows backward from the bladder into the ureters and kidneys, potentially causing swelling and damage.

4. Tumors or Cysts: Abnormal growths in or around the urinary tract can obstruct urine flow.

5. Kidney Stones: These can block the ureters, leading to hydronephrosis.

6. Neurogenic Bladder: Conditions that affect nerve function can impair bladder control, leading to urinary retention and hydronephrosis.

Treatment Options
The treatment for hydronephrosis depends on the underlying cause, the severity of the condition, and the age and health of the child. Here are some common treatment options:
1. Observation: In mild cases, especially if the hydronephrosis is not causing significant symptoms, doctors may recommend a watchful waiting approach, with regular follow-ups to monitor kidney function and size.

2. Medications: If infections are present, antibiotics may be prescribed. Pain management is also crucial, especially in cases where the child experiences significant discomfort.

3. Surgical Interventions: If there is a structural blockage, surgery may be necessary. Common procedures include:
- Pyeloplasty: This surgery removes the obstructed segment of the ureter and reattaches it to the kidney.

- Ureteral Stenting: Inserting a stent (like the double-J catheter your daughter has had) can help keep the ureter open and allow urine to flow.

- Nephrectomy: In severe cases where the kidney is irreparably damaged, removal of the affected kidney may be considered.

4. Endoscopic Procedures: These minimally invasive techniques can sometimes be used to relieve obstructions without the need for larger surgical incisions.

5. Management of Underlying Conditions: If hydronephrosis is due to VUR or other conditions, treating those underlying issues can help alleviate the hydronephrosis.

Alternative Approaches
While the current approach of managing hydronephrosis through pain management and stenting has been the standard, it’s essential to discuss with your healthcare provider about exploring other options. Some potential avenues include:
- Second Opinions: Consulting with a pediatric urologist or nephrologist who specializes in hydronephrosis may provide new insights or alternative treatment strategies.

- Advanced Imaging: Sometimes, further imaging studies like a renal scan can help determine the best course of action by assessing kidney function and urine flow dynamics.

- Minimally Invasive Techniques: Newer techniques and technologies are continually being developed, and a specialist may have access to innovative treatments that could be beneficial.

Conclusion
It’s understandable to feel frustrated and concerned about your daughter’s ongoing issues with hydronephrosis. The repeated surgeries and discomfort she has experienced can be overwhelming for both her and your family. It’s important to maintain open communication with her healthcare team, advocate for her needs, and explore all possible treatment options. Seeking a second opinion or consulting with a specialist may provide new perspectives on managing her condition effectively. Remember, the goal is to alleviate her pain and improve her quality of life while ensuring her kidneys remain healthy.

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