Sonographic visualization of the ureter in pregnancy

Early diagnosis and management of maternal ureterohydronephrosis during pregnancy

Maternal ureterohydronephrosis (UHN) is a common anatomical change during the evolution of pregnancy, diagnosed especially after the 20th week of pregnancy. The aim of the present study was to evaluate the stages of UHN during pregnancy, depending on the gestational age, and to monitor the symptomatology and the adequate management. A total of 58 pregnant women with UHN, hospitalized in the Constanta County Emergency Hospital, were included in the present study, and had nephrological monitoring using ultrasound examination. Right UHN was observed in all cases and left UHN was observed in only 67.24% of the cases. Regarding the gestational age, right UHN grade III was most commonly seen between 27 and 31 weeks of pregnancy (48.6% of total right UHN grade III from the studied group). The data showed that gestational age and grade of UHN had a highly dependent association in the studied group. The majority of our patients (67.24%) were symptomatic, and the most common complaint on presentation was lumbar pain. According to the visual analog scale (VAS) of the lumbar pain, the group could be distributed as follows: 17.24% with severe pain, 36.21% with moderate pain and 13.79% with mild pain. Eight pregnant women (13.79%) from the present study developed UHN due to passage of a ureteral stone, although the majority of the patients experienced complications with urinary tract infection and acute kidney injury. In addition, 97% of the symptomatic UHN responded to conservatory treatment and only 2 patients (3.45%) with severe symptomatic UHN needed ureteral stent insertion. Data analysis was performed using IBM SPSS Statistics 23. The study highlighted the existence of an association between gestational age and UHN grading.

Management of ureteric stone in pregnancy: a review

Background

Urolithiasis in pregnancy is a major health concern and is one of the most common causes for non-obstetrical abdominal pain and subsequent hospital admission during pregnancy. The incidence of urinary calculi during pregnancy varies in the range of 1/200 to 1/2000. Acute ureteric colic in pregnancy is associated with significant potential risks to both mother and fetus. Significant anatomic and functional changes occur in pregnancy which not only lead to stone formation but also create diagnostic dilemma. The diagnosis of ureteric calculi can be incorrect in about 28% of pregnant patients.

Main body

Management of ureteric stone during pregnancy is remaining to be a challenge for the treating urologist. Because of the inability to use good imaging options for the diagnosis confirmation and more invasive approach for the treatment, management continues to be difficult. The main threats are preterm labor with delivery and premature rupture of membranes. Other pregnancy complications are obstructive uropathy, gestational diabetes mellitus, recurrent abortions and pre-eclampsia. Management of diagnosed ureteric stone is unique in the pregnant population and requires multi-disciplinary care. It should be individualized for each patient and moves preferably from conservative to invasive approaches sequentially. With continued advancements in endourological techniques, few definitive treatment options are also available for such patients.

Conclusion

There are several lacunae related with the diagnostic imaging, medical expulsive therapy, reliability of ureteral stent/percutaneous nephrostomy insertions and safety of ureteroscopy during pregnancy. Herein, we review the management of ureteric stone during pregnancy, the various diagnostic modalities and treatment options with their advantages and disadvantages. We also proposed our management algorithm to deal with such clinical scenario in this particular population.

Nephrolithiasis in Pregnancy: Treating for Two

OBJECTIVES

To review the literature regarding the epidemiology of stone disease and develop a management algorithm based on current evidence and societal guidelines.

METHODS

A structured literature review was performed to determine highest quality of evidence guiding care for pregnant patients with symptomatic nephrolithiasis. PUBMED and EMBASE databases were searched using terms "pregnancy," "nephrolithiasis," or "pregnancy" and "renal colic" alone and in combination with "stone", "kidney stone," "ultrasound," "MRI," "CT," "percutaneous nephrostomy," "ureteral stent," or "ureteroscopy." All English-language abstracts were reviewed for relevance and full-length articles were reviewed for content. Articles published prior to 1990 were excluded, and priority for inclusion was given to multi-institutional studies and larger institutional studies, reflecting the highest level of current available evidence and most contemporaneous practice patterns.

RESULTS

Symptomatic nephrolithiasis affects less than 1% of pregnancies but poses unique diagnostic challenges due to the physiologic changes of pregnancy and risks of ionizing radiation exposure to the fetus. Ultrasound remains the imaging modality of choice. Most patients may be managed non-operatively, but drainage with percutaneous nephrostomy or ureteral stent may be performed if warranted. Growing evidence also supports the safety and efficacy of definitive stone treatment.

CONCLUSIONS

Though rare, symptomatic nephrolithiasis poses significant clinical challenges due to the need to minimize risk for both mother and fetus with diagnostic and therapeutic interventions. A multi-disciplinary approach is paramount, as is shared decision making with the patient at each step of care.

The Urological Association of Asia clinical guideline for urinary stone disease

The Urological Association of Asia, consisting of 25 member associations and one affiliated member since its foundation in 1990, has planned to develop Asian guidelines for all urological fields. The field of stone diseases is the third of its guideline projects. Because of the different climates, and social, economic and ethnic environments, the clinical practice for urinary stone diseases widely varies among the Asian countries. The committee members of the Urological Association of Asia on the clinical guidelines for urinary stone disease carried out a surveillance study to better understand the diversity of the treatment strategy among different regions and subsequent systematic literature review through PubMed and MEDLINE database between 1966 and 2017. Levels of evidence and grades of recommendation for each management were decided according to the relevant strategy. Each clinical question and answer were thoroughly reviewed and discussed by all committee members and their colleagues, with suggestions from expert representatives of the American Urological Association and European Association of Urology. However, we focused on the pragmatic care of patients and our own evidence throughout Asia, which included recent surgical trends, such as miniaturized percutaneous nephrolithotomy and endoscopic combined intrarenal surgery. This guideline covers all fields of stone diseases, from etiology to recurrence prevention. Here, we present a short summary of the first version of the guideline - consisting 43 clinical questions - and overview its key practical issues.

Review on diagnosis and management of urolithiasis in pregnancy: an ESUT practical guide for urologists

PURPOSE

Management of urolithiasis in pregnancy can be challenging for most urologists with diagnostic and treatment dilemma to ensure the best outcome for both mother and fetus. We wanted to review the literature for urolithiasis in pregnancy with a practical management guide for urologists.

METHODS

A non-systematic review of literature was carried out for all English language literature using Medline. To ensure a more comprehensive search, the review of diagnosis and management of pregnant patients with urolithiasis was carried out separately, by two authors independently. Due to diagnostic complexity, investigations (US, CT, MRI) carried out were assessed separately.

RESULTS

Our search included diagnostic studies such as US, CT and MRI (73, 20 and 27 articles, respectively) and management studies (55 articles in total). Details on etiology, radiation risk, safety of various diagnostic modalities, medications and treatment options are covered through an evidence-based approach. We provide a practical guide for urologists in what is clearly a stressful situation for patient and physician alike.

CONCLUSIONS

Urolithiasis in pregnancy needs a careful multidisciplinary management to achieve good outcomes for both mother and baby. Our review shows that a balanced approach for diagnosis and treatment seems to achieve the best outcomes in pregnancy.

Our ultrasonographic experience in the management of symptomatic hydronephrosis during pregnancy

INTRODUCTION

The aim of the present study was to document the role of ultrasound in the diagnosis and management of symptomatic hydronephrosis during pregnancy.

METHODS

In this study, we reviewed 36 consecutive cases of pregnant women whose pregnancy was complicated by symptomatic hydronephrosis. In all patients, management was initially conservative (analgesics and fluids) after hospitalization. The following criteria were used to indicate double-J stent placement under US guidance rather than a conservative treatment: persistent pain with no improvement after conservative treatment, progressive hydronephrosis (>2 cm dilatation of the renal pelvis) or presence of uterine contractions.

RESULTS

The mean patient's age was 25 years (17-35) and gestational age at clinical presentation was 24 weeks (13-37). 81 % of cases had a renal pelvis dilatation >2 cm, while in only 19 % of cases there was a hydronephrosis between 1 and 2 cm in diameter; however, calculi were confirmed only in 25 patients. 28 patients required an invasive management with double-J stent insertion under US guidance. The sensitivity and specificity of US in the etiological diagnosis of hydronephrosis during pregnancy was 83 and 91 %, respectively.

CONCLUSION

Conservative management with medical therapy and observation should be the first-line treatment approach. In our opinion a rapid ureteral decompression with the insertion of a ureteral double-J stent, under US visualization, is the safest method in the treatment of pregnant women with obstructed renal systems.

Renal pelvis rupture during pregnancy: diagnosing a confusing source of despair

We present an impressive case of a pregnant woman presenting with severe right flank pains. A rare rupture of the right renal pelvis turned out to be the cause of her problems. Renal pelvis rupture in pregnancy is difficult to diagnose. It is easily confused with other more prevalent diagnoses, like hydronephrosis, ureteral distension, renal calculus and pyelonephritis. Ultrasonography is not always conclusive. Pyelography seems to be a good diagnostic tool, this case shows that MRI is another option. Renal pelvis rupture can be effectively treated with the insertion of a JJ-stent.

Renal stones in pregnancy

Diagnosis and treatment of renal stones during pregnancy is a complex problem. Risks to the fetus from ionising radiation and interventional procedures need to be balanced with optimising clinical care for the mother. Management of such patients requires a clear understanding of available options, with a multidisciplinary team approach. In this review, we discuss the role of different diagnostic tests including ultrasound, magnetic resonance urography, and computerized tomography. We also provide an update on recent developments in the treatment of renal stones during pregnancy. Expectant management remains first-line treatment. Where definitive treatment of the stone is required, new evidence suggests that ureteroscopic stone removal may be equally safe, and possibly better than traditional temporising procedures.

Management of symptomatic ureteral calculi during pregnancy: Experience of 23 cases

Purpose:

To present our experience in the management of symptomatic ureteral calculi during pregnancy.

Materials and Methods:

Twenty-three pregnant women, aged between 19 and 28 years presented to the obstetric and urology departments with renal colic (17 cases, 73.9%) and fever and renal pain (6 cases, 26.1%); suggesting ureteric stones. The diagnosis was established by ultrasonography (abdominal and transvaginal). Outpatient follow-up consisted of clinical assessment and abdominal ultrasonography. Follow-up by X-ray of the kidneys, ureter, and bladder (KUB), or intravenous urography (IVU) was done in the postpartum period.

Results:

Double J (DJ) stent was inserted in six women (26%) with persistent fever followed by extracorporeal shock wave lithotripsy (ESWL) one month post-partum. Ureteroscopic procedure and pneumatic lithotripsy were performed for 17 women (distal ureteric stone in 10, middle ureter in 5, and upper ureteric stone in 2). Stone-free rate was 100%. No urologic, anesthetic, or obstetric complications were encountered.

Conclusions:

Ureteroscopy, pneumatic lithotripsy, and DJ insertion could be a definitive and safe option for the treatment of obstructive ureteric stones during pregnancy.

Urinary Stone Disease during Pregnancy: One Problem, Two Patients

Urolithiasis in pregnant women is a quite uncommon event: about one in 1500 pregnancies is complicated by urinary calculi and it occurs in 80–90% of the patients during the second or third trimester of pregnancy.

Several factors may predispose stone formation in the upper urinary tract during pregnancy: the “physiological” hydronephrosis, the gestational hypercalciuria, and an elevation in both glomerular filtration rate and renal plasma flow, associated with an increase of creatinine clearance and higher renal filtration rate of sodium, calcium, and uric acid. Flank or abdominal pain is the most common symptom associated with evident or microscopic hematuria. Differential diagnosis of pain varies according to its location: it could be of gastrointestinal or gynecologic origin.

Diagnosis is previously based on ultrasound evaluation. The use of radiation must be avoided during pregnancy, even if the risk of fetal injures depends on gestational age and radiation dosage. Most of the symptomatic ureteral stones affecting pregnant women pass spontaneously: therefore therapy could be conservative (hydration, analgesia, antibiotics, antiemetics) in the most of cases, although in the 15–30% of the cases it is necessary to adopt an active treatment, like percutaneous nephrostomy drainage, ureteral stent insertion or ureterorenoscopy.

Management of urinary calculi in pregnancy: a review

Nephrolithiasis during pregnancy can represent a clinical dilemma because of potential risks to both mother and fetus. While the incidence of symptomatic nephrolithiasis during pregnancy varies between 1 in 244 to 1 in 2000 pregnancies, the actual incidence is likely to be higher. A significant proportion of patients with asymptomatic renal calculi are detected incidentally in the nonpregnant population compared with pregnant women. Factors that contribute to the diagnostic challenges include anatomic and physiologic changes to the female urinary tract during pregnancy and the limitations on the use of ionizing radiation. The treatment of such patients requires a multidisciplinary team approach involving the urologist, obstetrician, and radiologist. The potential hazards of intervention (either surgical or medical) and anesthesia need to be considered carefully.

Management of Symptomatic Urolithiasis During Pregnancy

Urinary calculi during pregnancy present not only a diagnostic challenge but also a management dilemma. In this retrospective study, we describe our experience with diagnosis and management of symptomatic urolithiasis in pregnant women. A total of 18 pregnant women were treated for urolithiasis at the Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital, between 1999 and 2004. The incidence of symptomatic urolithiasis during pregnancy was 0.35%. Of the 20 stones found, nine were on the right side and 11 were on the left, and two patients had bilateral urinary stones. Most urolithiasis cases during pregnancy (55.5%) occurred in the third trimester. Flank pain (94.4%) was the most common clinical presentation. Conservative management was successful in 10 patients until the end of pregnancy and then definite treatment was performed. In four patients, a double-J stent was inserted successfully for persistent pain. In three cases with persistent pain, failure of double-J stent placement was treated with ureteroscopic lithotripsy under epidural anesthesia. One patient received percutaneous nephrostomy for persistent renal colic and pyonephrosis. Ultrasonographic evaluation of pregnant women with suspected renal colic is a reasonable diagnostic procedure. Ureteroscopy is another choice when conservative treatment fails.

Urolithiasis in Pregnancy: Current Diagnosis, Treatment, and Pregnancy Complications

Urolithiasis complicates up to one in every 200 pregnancies; consequently, the practicing obstetrician should be aware of the symptoms of urolithiasis, the diagnostic procedures available for its diagnosis, and their associated risks. These include ultrasound, urography, and magnetic resonance imaging. Diagnosis of urolithiasis during pregnancy can be a challenge as a result of the normal physiological changes of pregnancy. Conservative management is the first-line treatment for noncomplicated urolithiasis in pregnancy. If spontaneous passage of the stone does not occur or if complications develop, urologic consultation should be obtained. Several obstetric complications have been associated with urolithiasis, including preterm labor and preterm premature rupture of membranes, although the reported rates of these complications in association with urolithiasis vary widely and overlap normal background rates. Given that urolithiasis will be encountered by most obstetricians, and that obstetricians are often on the front line of management for this condition, an appreciation of current diagnostic modalities, treatment protocols, and associated potential obstetric complications is warranted.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that urolithiasis is common in pregnancy, state that there are a variety of diagnostic procedures, summarize that conservative treatment is usually successful, and explain that complications of pregnancy usually occur when there is failure of conservative treatment.

Imagerie de la lithiase urinaire : « Trois en un »

Urinary lithiasis is very common among the general population, with a high prevalence level. In rich countries it is mainly located inside the upper urinary tract. Helical CToperated with newer devices is the most accurate modality to provide all needed information: diagnosis of stone without contrast medium injection, morphology (size, number) and localization, diagnosis of urinary obstruction, urinary tract aspect and all kind of differential diagnosis in emergency. It must be used during follow up to diagnose residual fragments. Multiplanar reconstructions are essential for the clinicians; but diagnosis is interpreted by scrolling axial views with dynamic analysis on computer screen. Low-dose helical CT is today available. Helical CT provides an "all-in-one" examination. It should soon replace combined plain film-ultrasonography performed in an emergency context of renal colic and intravenous urography for pre- and post-treatment assessments.

Doppler waveform of the ureteric jet in pregnancy

We have shown that the function of the bladder vesicoureteric junction (VUJ) can be studied by the Doppler waveform of the ureteric jet, and this reflects the active sphincteric mechanism of the VUJ. We wished to investigate if the hormonal changes of pregnancy cause any alteration of VUJ function. A total of 107 pregnant women and 375 nonpregnant women were recruited. Three scans, 20 and 32 weeks of gestational age and 3 months postpartum, were done. The occurrence of a monophasic waveform in the nonpregnant group was 1.9%. In the pregnancy group, this was 18.7%, 41.1% and 1.6% at 20, 32 weeks of gestational age and 3 months postpartum, respectively. The difference in occurrence of the monophasic waveforms was statistically significant (both p = 0.0005 at 20 and 32 weeks). This suggests an adverse hormonal effect on the vesicoureteric junction during pregnancy, and may be a factor in the increased risk of UTI in pregnancy.

Ureteroscopy as a first-line intervention for ureteral calculi in pregnancy

BACKGROUND AND PURPOSE

Renal colic in pregnancy presents a diagnostic and therapeutic challenge. When conservative therapy fails or is not indicated, temporary measures such as ureteral stenting are often chosen as a first-line intervention, postponing definitive management until after delivery. We propose that advances in endoscopic equipment and anesthesia techniques dictate a more definitive strategy.

PATIENTS AND METHODS

A retrospective analysis was performed on 10 consecutive pregnant patients presenting with renal colic necessitating intervention between April 1998 and April 2000. The mean patient age was 23 (range 17-31) years. One patient presented during the first trimester, six in the second, and three in the third. Four of the patients had a history of stone disease. All patients had flank pain at presentation, six on the left side and four on the right. Hematuria, fever, and nausea were present in eight, one and two patients, respectively.

RESULTS

Ultrasound scanning was performed in all patients and showed a low sensitivity (28.5%) when compared with intraoperative findings. Ureteroscopy (rigid and/or flexible) was performed as a first-line intervention in six patients, in two of whom no stone was found. Percutaneous nephrolithotomy was carried out in one patient presenting with a nephrostomy tube. Double-J stents were placed in only three patients with specific indications, namely urinary infection, late gestational phase, and difficult ureteroscopy secondary to a narrow ureter. No obstetric or urologic complications were noted. The mean size of the stones retrieved in seven patients was 7 mm.

CONCLUSIONS

Ureteroscopy may be considered a safe and effective first-line definitive therapeutic option in pregnant patients requiring intervention for stone disease.

Rigid ureteroscopy in pregnant women

OBJECTIVE

To report our experience with rigid ureteroscopy in pregnant women.

PATIENTS AND METHODS

Ten pregnant women (mean age 25 years, SD 4.5, range 22-33) with ureteric stones were treated by ureteroscopy. The mean (SD, range) gestation time was 24 (6.5, 19-33) weeks. A standard rigid ureteroscope of 11.5 F was used in eight patients and 9.5 F in two. The procedure was carried out with no ureteric dilatation in three patients and with easy dilatation in seven. Fluoroscopy was not used before or during ureteroscopy in any case. Ultrasonography was available throughout the procedures for constant renal and obstetric monitoring.

RESULTS

Mid and lower ureteric stones were extracted by basket or forceps in three patients and had to be disintegrated by ultrasound in two. Upper ureteric stones were displaced to the kidney, with placement of double-pigtail ureteric stents, in three patients who were subsequently treated after delivery. Ureteric oedema was seen in one patient and the endoscopic findings were normal in the remaining patient. There were no obstetric complications. Two patients had a urinary tract infection and one complained of stent-induced bladder irritation.

CONCLUSIONS

Rigid ureteroscopy is a safe and reliable method in the diagnosis and treatment of ureteric calculi during pregnancy. The procedure can be performed with ultrasonographic monitoring and without using fluoroscopy.

Dilatation of the urinary tract during pregnancy: proposal of a curve of maximal caliceal diameter by gestational age

OBJECTIVE

Dilatation of the urinary tract is common during pregnancy, but the limits between physiologic and pathologic dilatation are unknown. Our purpose was to establish the pattern of physiologic urinary tract dilatation during pregnancy.

STUDY DESIGN

This was a cross-sectional study. The maximal caliceal diameter was measured by ultrasonography at different weeks' gestational age in 1506 pregnant and 181 postpartum women. A curve with the 90th, 75th, and 50th percentiles was drawn for each kidney.

RESULTS

Fifty-three (6%) pregnant and postpartum women had some degree of dilatation. The right kidney was more frequently and severely affected, as were nulliparous women. The 90th percentile of maximal caliceal diameter of the right kidney increased about 0.5 mm/wk up to 24 to 26 weeks, about 0.3 mm/wk up to 31 to 32 weeks, and remained stable until term. The left maximal caliceal diameter attained 8 mm around week 20 to 24 and remained stable until term. Only 6% had dilatation in the postpartum period.

CONCLUSION

A normal curve of dilatation of the urinary tract is proposed.

Urinary calculi during pregnancy. When are they cause for concern?

Urolithiasis during pregnancy, though rare, can be challenging both diagnostically and therapeutically. It is helpful if the physician is quick to suspect the presence of stones in the presence of appropriate signs and symptoms, particularly flank pain and tenderness, hematuria, or unresolved bacteriuria. Ultrasonography is the diagnostic imaging method of choice, but modified intravenous urography should be performed whenever this study is necessary for a prompt diagnosis. In the absence of sepsis, renal failure, or intractable pain, conservative management with hydration, analgesics, and (if infection is present) antibiotics is the favored initial approach. If conservative management fails, stent insertion or placement of a percutaneous nephrostomy tube may be appropriate. Ureteroscopy with stone manipulation for distal ureteral stones during pregnancy has also been reported in some cases. If these methods fail, open surgery should be used for stone removal.

Fast imaging MR assessment of ureterohydronephrosis during pregnancy

PURPOSE

to assess the value of the fast imaging sequence called RARE-MR-Urography (RMU) for the diagnosis of pathologic ureterohydronephrosis during pregnancy.

MATERIALS AND METHODS

15 pregnant women with an acute flank pain were examined with RMU. Results were compared with those of ultrasonography (US), X-rays, and the evolution of symptoms.

RESULTS

the accuracy of RMU in the detection of urinary tract dilatation and the localization of the level of obstruction was excellent (100%). The determination of the type of obstruction, intrinsic vs. extrinsic, was always exact. RMU alone cannot specify the exact nature of the intrinsic obstruction. Ultrasonography gave less sensitive information in terms of level (60%) and type of obstruction (53%).

CONCLUSION

RMU is able to differentiate a physiological from a pathologic ureterohydronephrosis during pregnancy. It could be considered as a procedure of choice for special cases when US failed to establish this differential diagnosis.

Management of acute ureteral obstruction in pregnancy utilizing ultrasound-guided placement of ureteral stents

Of 6,275 pregnancies seen at our institution over a two-year period, 5 patients required operative intervention for acute urinary obstruction unresponsive to medical management. Ultrasonography was able to definitively diagnose the presence of an obstructing calculus in 4 of 5 patients. Using ultrasound guidance, 7 indwelling ureteral stents were successfully placed with local anesthesia supplemented by intravenous sedation. Complications consisted of distal stent migration in 1 patient. This method of management was successful for symptomatic nephrolithiasis in a pregnant renal transplant patient. Endoscopic placement of ureteral stents under ultrasound guidance is an effective, safe method of urinary decompression, with no radiation risks imparted to the mother or fetus. Definitive therapy then can be safely deferred to the post-partum period.

Renal colic in pregnancy

Renal calculi are an infrequent but significant management problem during pregnancy. We reviewed all cases of renal colic occurring during pregnancy between 1979 and 1990 at Grace Hospital, a tertiary care obstetrical hospital in Vancouver, British Columbia. Of the patients 80 had a discharge diagnosis of renal colic and pregnancy during this 11-year period. Calculi were confirmed in 57 patients. Of the patients 66% were multiparous and 99% of the calculi occurred during either the second or third trimester. The most common symptom was flank pain seen in 89% of the patients, while greater than 95% displayed either microscopic or gross hematuria. Methods of radiographic diagnosis included ultrasonography and limited stage excretory urography. A total of 84% of patients passed stones spontaneously. Indications for urological or obstetrical intervention included persistent pain, sepsis, progressive hydronephrosis, solitary kidney or high grade obstruction. There were 37 procedures done in 23 patients. The most common procedure was placement of a ureteral stent. The complication rate associated with intrapartum intervention and stent passage in the 23 patients was 16%. All patients with a ureteral stent subsequently had spontaneous vaginal delivery without complication. A scheme for managing renal calculi in pregnancy is presented.