Bilateral Hydroureteronephrosis with a Hypertrophied, Trabeculated Urinary Bladder

Abstract

Bilateral hydroureteronephrosis involves the dilatation of the renal pelvis, calyces and ureter; it develops secondary to urinary tract obstruction and leads to a build-up of back pressure in the urinary tract, and it may lead to impairment of renal function and ultimately culminate in renal failure. Although clinically silent in most cases, it can be diagnosed as an incidental finding during evaluation of an unrelated cause. In a minority of patients, it presents with signs and symptoms. Renal calculus is the most common cause, but there are multiple non-calculus aetiologies, and they depend on age and sex. Pelviureteric junction obstruction, benign prostatic hypertrophy, urethral stricture, neurogenic bladder, retroperitoneal mass and bladder outlet obstruction are some of the frequent causes of hydroureteronephrosis in adults. The incidence of non-calculus hydronephrosis is more common in males than in females. Ultrasonography is the most important baseline investigation in the evaluation of patients with hydronephrosis. Here, we report a rarely seen case of bilateral hydroureteronephrosis associated with a hypertrophied, trabeculated bladder in an adult male cadaver, suspected to be due to a primary bladder neck obstruction, and analyse its various other causes, clinical presentations and outcomes.

Keywords: hydronephrosis; prostatic hyperplasia; ultrasonography; urinary bladder neck obstruction; urodynamics.

Figure 1A

Bilateral hydronephrotic kidneys, hydroureters and hypertrophied, trabeculated urinary bladder. Kidney shows bilateral, multiple communicating cysts; ureters are dilated bilaterally. RK: Right kidney; LK: left kidney; RRV: Right renal vein; LRV: Left renal vein; AA: Abdominal aorta; RU: Right ureter; LU: Left ureter.

Figure 1B

Sagittal sections of hydronephrotic kidneys, hydroureters and interior of the hypertrophied bladder showing trigone. Renal pelvis and calyces are markedly dilated; pyramids and medulla are attenuated; bladder shows trabeculated anterior wall; both ureterovesical junctions are patent and probed; urethral orifice was patent and probed RPR: Dilated right renal pelvis; RPL: Dilated left renal pelvis; RU: Right hydroureter; LU: Left hydroureter; TG: Trigone; RUO: Right ureteric orifice; LUO: Left ureteric orifice; UO: Urethral orifice.

Figure 2A

Sagittal section of right kidney Dimensions: Kidney: 88.3 mm × 41.9 mm × 46.1 mm; cortical thickness: 15.05 mm (range: 14.7 mm to 15.4 mm); renal pelvis: 57.9 mm × x 28.6 mm × 30.9 mm; Ureter length: 260 mm; width max: 19.5 mm; min: 4.7 mm; intramural length: 26.8 mm. RP: Dilated renal pelvis; RC: Dilated renal calyces; P: Attenuated renal pyramids; U: Dilated ureter

Figure 2B

Sagittal section of left kidney Dimensions: Kidney: 84.1 mm × 29.7 mm × 34.8 mm; cortical thickness: 12.8 mm (range: 11.5 mm to 14.1 mm); renal pelvis: 58.7 mm × 24.9 mm × 22.1 mm; Ureter: length: 278 mm; width max: 14.2 mm; min: 3.9 mm; intramural length: 27.1 mm. RP: Dilated renal pelvis; RC: Dilated renal calyces; P: Attenuated renal pyramids; U: Dilated ureter

Figure 3A

Interior of hypertrophied urinary bladder Enlarged bladder shows thickened and trabeculated anterior wall; both ureterovesical junctions are probed and ureteric orifices are made out bilaterally; urethra was patent and probed Dimensions: 142 mm × 135 mm × 6.3 mm; Trigone interureteric distance: 36.7 mm; uretero-urethral distance: 57.6 mm; diameter of ureteric orifice left: 1.5 mm; right: 1.2 mm; urethral orifice: 3.3 mm × 1.9 mm. TB: Trabeculated wall of the bladder; TG: Smooth trigone; RUO: Right ureteric orifice; LUO: Left ureteric orifice; UO: Urethral orifice

Figure 3B

Enlarged view of trigone of the bladder TG: Smooth trigone; RUO: Right ureteric orifice; LUO: Left ureteric orifice; UO: Urethral orifice

Figure 4A

Cut section of urinary bladder showing transitional epithelium (H & E stain, 10X magnification) Sections of the bladder wall showing the attenuated transitional epithelium with hypertrophied detrusor muscular layer TE: Transitional epithelium

Figure 4B

Cut section of urinary bladder showing hypertrophied detrusor muscle fibres (H & E stain, 10X magnification) DM: Hypertrophied detrusor muscle fibres

Figure 4C

Cut section of hydronephrotic kidney showing attenuated renal parenchyma (H & E stain, 4X magnification) Sections of the kidney showing interstitial fibrosis with chronic inflammatory infiltrate in interstitium; many of the glomeruli show periglomerular fibrosis and some of them were completely hyalinised; renal tubules show dilation with amorphous eosinophilic material deposition in the lumen (thyroidisation); blood vessels show thick hyalinised vessel wall and the transitional epithelium of the pelvis was attenuated. RC: Renal corpuscles

Figure 4D

Cut section of hydronephrotic kidney showing hyalinised glomerulus (H & E stain, 10X magnification) HG: Hyalinised glomerulus

Figure 4E

Cut section of hydronephrotic kidney showing thyroidsation of renal tubules (H & E stain, 10X magnification) TT: Thyroidsation of renal tubules