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A 32 year old man presents with right loin pain after a drinking binge. His friends have urged him to attend the Emergency Department because he always complains of right loin pain after drinking in their company and they would like him to get to the bottom of it. He describes having right loin pain after heavy drinking for a number of years. This generally lasts from hours to days depending on how much he has drunk. At one point he describes stopping drinking for 6 weeks and was pain free during that time. He has a family history of renal colic. His renal function is normal.
A point of care renal ultrasound is performed
Longitudinal view of the right kidney shows hydronephrosis.
Transverse view of the right kidney
In the transverse view, the balloon shaped pelvis is over 7cm in diameter
Transverse view with colour Doppler. There is no flow with Colour Doppler within the anaechoic structure
Transverse view in slow motion. This is a slowed down sweep through the right kidney in the transverse plane. Note that the pelvic cystic structure is not entirely concave and communicates with the dilated calyces excluding a renal cyst. This is severe hydronephrosis. The parenchyma is thin.
A CT with contrast was organised which showed a pelviureteric junction stenosis with cortical parenchymal thinning secondary to extrinsic compression by an ectopic inferior right renal artery
CT upper pole coronal view
Mid pole coronal view
lower pole coronal view
The patient was referred for a pyeloplasty with the pelviureteric anastamosis being placed anterior to the aberrant vessel.
Hydronephrosis from congenital PUJ obstruction has an incidence of around 1 in 1000-1500. The cause for this is most likely functional, resulting in neuromuscular incoordination of the ureteropelvic junction secondary to abnormalities in the smooth muscle of the pelvis and ureter. Physical obstruction of the ureter by compression from an aberrant renal vessel is observed but may not actually be the cause of the obstruction.
The renal arteries usually arise from the aorta below the superior mesenteric artery at L1-L3. The right renal artery is longer, passing posterior to the IVC, right renal vein, head of pancreas and descending part of the duodenum to join with the aorta. Each renal artery divides into anterior and posterior divisions at or very close to the hilum of the kidney and then further divides into segmental arteries to supply the respective segments of the kidney.
Accessory or aberrant arteries are common (30% of the population). The term applies equally to an additional artery in the renal pedicle, or to a vessel entering the kidney directly at either pole, whether derived from the main renal artery, from the aorta or from a branch of the aorta
In this case, the hydronephrosis was so severe that it may have been difficult to differentiate it from other pathology. The following are some mimics of hydronephrosis.
Mimics of Hydronephrosis:
- Extrarenal pelvis
- Parapelvic cysts
- Prominent renal vasculature and vascular malformations.
- Easy to confuse with hydronephrosis.
- Anatomical variant (10% of population)
- The renal pelvis is outside the renal sinus and therefore not surrounded by fat
- The pelvis is larger and more distensible
- Usually asymptomatic but stone formation and infection have been reported
- Unlike hydronephrosis it is not associated with dilated calyces, parenchymal thinning, hydroureter or enlarged kidney
- Tip : An easy way to differentiate an extra renal pelvis from hydronephrosis is to place the patient prone . In the prone position , hydronephrosis will remain, an extrarenal pelvis will collapse
- Easy to confuse with hydronephrosis
- Describes cysts around the renal pelvis or renal sinus
- The cysts do not communicate with the collecting system
- Probably lymphatic in origin
- Mainly asymptomatic but may cause haematuria, hypertension, hydronephrosis or become infected
- Unlike hydronephrosis, it is not associated with dilated calyces, parenchymal thinning, hydroureter or enlarged kidney
- More spherical in shape than hydronephrosis
- Tip: In the transverse view the cyst does not appear connected with the calyceal system
- Differentiation with hydronephrosis is confirmed with a CT scan with contrast
Prominent renal vasculature and vascular malformations
- Easy to differentiate from hydronephrosis with colour Doppler. Vascular structures will demonstrate flow
- Korean J Intern Med. 2003 Mar; 18(1): 57–60. Hydronephrosis by an Aberrant Renal Artery: A Case Report
Byoung Seok Park, M.D., Taek Kyun Jeong, M.D., Seong Kwon Ma, M.D., Soo Wan Kim, M.D., Nam Ho Kim, M.D., Ki Chul Choi, M.D., and Yong Yeon Jeong, M.D.*
- Unusual course of accessory renal artery and its clinical significance: a case report T. Ramesh Rao1, Prakashchandra Shetty1 and Suresh Rao2* 1Department of Anatomy and Cell Biology Histology, American University of Antigua , Manipal Campus, KMC International Center, Manipal University, Manipal, Karnataka, India
- Double Accessory Right Renal Arteries.Dr. Neelesh Kanaskar1 Dr. Vaishali Paranjape 2 Dr. Jyoti Kulkarni3Sapna Shevade41,2,3,4 (Department of Anatomy, Dr. D.Y.Patil Medical College/Dr. D.Y.Patil University, Pune, India)
- HYDRONEPHROSIS & UPJ OBSTRUCTION DUE TO AN ACCESSORY RENAL ARTERY By: Tanner Burton https://www.ornh.mb.ca/wcm-docs/docs/rw_2018/burton,_tanner.
- Sunday Abba, Amanuel Tesfay, Peter Ekanem. ACCESSORY RENAL ARTERY AND ITS CLINICAL SIGNIFICANCE. Int J Anat Res 2013;03:155-57.
- Baskin LS. Congenital ureteropelvic junction obstruction. In: Post T, ed. UptoDate. Waltham, MA: Wolters Kluwer; 2018.
- Rev Urol. 2001 Winter; 3(1): 42–51. PMCID: PMC1476031 PMID: 16985690 UPJ Obstruction in the Adult Population: Are Crossing Vessels Significant? Michael Grasso, III, MD, Robert P Caruso, MD, and Courtney K Phillips, MD
- The Ultrasound Mimics of Hydronephrosis May 10, 2019 https://www.renalfellow.org/2019/05/10/the-ultrasound-mimics-of-hydronephrosis/
- Clin Case Rep. 2017 Oct; 5(10): 1720–1721. Published online 2017 Aug 24. doi: 10.1002/ccr3.1143 Extrarenal pelvis mimicking hydronephrosis: a case for caution Abhilash Koratala corresponding author 1 and Deepti Bhattacharya 1
- Urol Clin North Am. 1998 May;25(2):289-93.Crossing vessels. Endourologic implications.Gupta M1, Smith AD.Author information Department of Urology, Columbia University, New York, New York, USA
- Int J Exp Pathol. 2011 Jun; 92(3): 168–192. Congenital ureteropelvic junction obstruction: human disease and animal models
Julie Klein,*† Julien Gonzalez,*† Mathieu Miravete,*† Cécile Caubet,*† Rana Chaaya,*† Stéphane Decramer,*†‡ Flavio Bandin,‡ Jean-Loup Bascands,*† Bénédicte Buffin-Meyer,*† and Joost P Schanstra*
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