Ultrasound: Urologist s Third Arm Evaluation and Management of Hydronephrosis during pregnancy Principles of Ureteral Jets

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1 Ultrasound: Urologist s Third Arm Evaluation and Management of Hydronephrosis during pregnancy Principles of Ureteral Jets Majid Eshghi, MD, FACS, MBA Professor of Urology, New York Medical College Chief Section, Endourology and Minimally Invasive Urology Westchester Medical Center How do you get to Carnegie Hall...? Practice Practice Practice How do you get to Renal Hilum? Probe Probe Probe Ultrasound probe becomes an extension of your hand: Urologist s 3 rd arm Make a point of having an ultrasound machine readily available next to your examination table

2 Practice Practice Try to improve your technique by practicing on yourself or colleagues Neck, wrist, right kidney, supra pubic area Practice imaging on patients with known renal lesions such as tumor, hydronephrosis or stone Whenever possible compare to other available images such as CT, MRI or IVU Position yourself comfortably. Otherwise imaging becomes awkward with poor quality and a tendency to terminate imaging quickly. Ultrasound Evaluation of Hydroureteronephrosis of Pregnancy Usually begins in 2 nd trimester involves 90% of pregnancies by the 26 th 28 th wks Dilatation increases up to the 30 th wk of gestation and remains stable for the remaining 10 wks Incidence of dilatation greatest in nulliparous pts. Subsides within the first month after parturition May persist longer More severe on the right side Ureteral dilatation Does Not occur below pelvic brim

3 The Gravid Kidney Resistive index Elevated secondary to obstruction renal vascular resistance 2/2 prostaglandins avoid NSAIDs prior to U/S Most evident in first 6 48h A difference of more than 0.1 from side to side suggestive of obstruction Overall sensitivity: % Less sensitive for partial vs complete obstruction RI = 0.9 RI = 0.7 Obstructed Normal

4 Evaluation of renal pelvic dilatation during pregnancy Normal limits of renal pelvic dilatation typically does not exceed 2.8cm on right and 1.8cm on left Gravid uterus compresses ureters at pelvic brim More pronounced on R vs L (85% vs 15%) dextrarotation of uterus ureteral compression by engorged uterine vein CROSS-SECTIONAL SAGITTAL A P measurement SAGITTAL TRANSVERSE

5 Right vs Left calyceal dilatation Corticomedullary Junction: Measurement of RI

6 RI calculations various scenarios ? (low RI in renal parenchyma indicative of high grade stenosis) 0.8 RI is normal during pregnancy Frequency of hydronephrosis is not related to the number of pregnancies Right Kidney (mm) Left Kidney (mm) Calyceal diameter (mm) First Trimester Second and Third Trimester >18 >15 >10 >27 >18 >10

7 Classification of fetal hydronephrosis Ureteral Jets Doppler waves focused on the bladder base and trigone. Pulsatile efflux of urine demonstrates the appearance of a red flame which is referred to as Ureteral Jets. This requires strong ureteral pulsatile flow.

8 Throwing Flame Strong Left Ureteral Jet Twinkle: Reverberation of doppler waves against a calculus.

9 Ureteral Jet Fire Breathing Dragon

10 Ureteral jet Evaluation during Pregnancy Ureteral jet frequency decreases during normal pregnancy Findings suggestive of ureteral obstruction Asymmetry of ureteral jets absence of flow sluggish continuous flow from affected side Similar findings may be seen in asymptomatic pregnant women diminished ureteral smooth muscle tone extrinsic ureteral compression by the gravid uterus No correlation between the degree of hydronephrosis and mean jet frequency

11 Ureteral jets in pregnancy Absence of jets 10 min of scanning Asymetry of jets.30 min Significant variation Hydration affects it The urine density differences contribute to visualization of jets Frequency decreases during pregnancy No correlation between jet frequency and degree of hydronephrosis Absence of jets is reported in % of asymptomatic pregnant women Ureteroscopy With Ultrasound Guidance +/ safety guidewire Ureteral access obtained with an 8F/9.8F rigid ureteroscope Flexible ureteroscopy if necessary Lithotripsy modality Holmium laser: fetal exposure to cyanide?? Ultrasonic: potential fetal hearing damage?? Real time continuous fetal monitoring +/ stent placement ( no strings attached )

12 Dilated Renal Pelvis Ultrasound Findings No Jets on the Right

13 Rt Flank Pain 26 weeks gestation Bedside Ultrasound Assistant Surgeon by bedside monitoring the affected kidney.

14 Intra op ultrasound Summary 1 1. Hydro (more severe on the right, no dilation below pelvic brim) begins in 2nd trimester and increases up to the 30 th week. 2. Hydro subsides within the first month after parturition. 3. A difference of more than 0.1 RI from side to side suggests obstruction. 4. Ureteral jets is useful to assess ureteral patency.

15 Summary 2 5. Renal pelvic dilation typically does not exceed 2.8 cm on the right and 1.8 cm on the left 6. Wrap the lower torso with lead apron for possible C ARM 7. Placement of ultrasound probe in lower quadrant for monitoring of lower ureteral stone. Ultrasound First Thank You

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