C.D. Creevy

The results of y plasty after five to twenty-four years: a review of seventy-three operations.

While intermittent hydronephrosis from obstruction at the ureteropelvic junction is said by Troup to have been recognized as early as 1672, over two hundred years elapsed before Trendelenburg first tried to correct it surgically in 1886. Causative lesions may be congenital or acquired: included are strictures, accessory vessels to the lower pole, fascial sheets and bands (fig. 1); postinflammatory fibrosis external to the junction; valves as well as granulomas and polyps of the mucosa; high attachment of the ureter to the pelvis; nephroptosis (fig. 2); and neuromuscular dysfunction. Combinations of two or more of these are common. It may be that accessory vessels and ptosis are more often contributory than exciting causes, and it is uncertain whether high ureteral attachment is a cause or an effect of hydronephrosis (fig. 3). The exact nature of neuromuscular dysfunction is unsettled; spasm of the junction, hypotonia of the pelvis, and dysinnervation of both have been suggested as causes, but the term real1y means only that the ureter is normal and the pelvis dilated in the absence of demonstrable anatomical obstruction. The disorder is usually discovered during urography done because of renal pain, or of persistent or recurrent urinary infection. The essential feature is a dilated pelvis with a normal ureter; the nature of the underlying lesion may or may not be detectable. If pain is unmistakably renal, or if the hydronephrosis is infected, one concludes that surgical treatment is needed. If, however, the symptoms are atypical or the hydronephrosis is small, particularly in the absence of infection, additional diagnostic measures are needed. Distension of the renal pelvis through an ureteral catheter may prove the relationship between hydronephrosis and pain by reproducing the latter, but only if the patient is unaware of the purpose of the maneuver; otherwise suggestion may cause confusion. However, if the pain produced by distension differs in character and in location from that of the original complaint, it is safe to assume that the origin of the symptoms is extrarenal. The delayed retrograde pyelogram is also valuable. If one fills the pelvis with contrast agent, removes the catheter, and has the patient walk about for ten minutes, radiography should show an empty or virtually empty pelvis. Delay in evacuation, particularly if the calyces are clubbed, strongly suggests genuine obstruction. As Nesbit recently emphasized, a patient may have genuine renal pain, yet have a normal urogram between attacks, whereas one made during pain, either spontaneous or induced by diuresis, may disclose frank hydronephrosis. Differential diagnosis may be difficult in a patient who complains of digestive disturbances and who proves to have hydronephrosis only after studies of the