983980 JFM Journal of Feline Medicine and SurgeryLemieux et al

Original Article

Journal of Feline Medicine and Surgery

Minimal renal pelvis dilation 2021, Vol. 23(10) 892­–899

© The Author(s) 2021
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DOI: 10.1177/1098612X20983980
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pyelography: a retrospective study by the American Editorial Office (AAFP)

for publication in JFMS

of 82 cases (2012–2018)

Charles Lemieux1 , Catherine Vachon1, Guy Beauchamp2

and Marilyn E Dunn1

Abstract
Objectives   The aim of the study was to describe renal pelvis (RP) and ureteral ultrasonographic measurements
in a population of cats with confirmed benign ureteral obstruction (UO) by antegrade pyelography. The secondary
objective was to further describe clinical findings associated with minimally dilated obstructed kidneys in an attempt
to better understand its occurrence.
Methods   Retrospective case series of cats diagnosed with benign UO were confirmed by antegrade pyelography.
Medical records were reviewed and signalment, diagnostic imaging results, serum creatinine (SCr) concentration
and urine culture results were recorded. Each obstructed kidney was categorized into two groups: group 1 included
all RP measurements ⩽4 mm and group 2 included all RP measurements >4 mm.
Results   A total of 82 cats with 114 obstructed ureters met the inclusion criteria. Fifty (61%) cats had a unilateral UO
and 32 (39%) had a bilateral UO. Thirty (26%) kidneys were included in group 1 while 84 (74%) were included in
group 2. Nine (8%) kidneys had an RP dilation ⩽2 mm. Median RP and ureteral diameters were 6.6 mm (range 1.1–
37.0 mm) and 3.2 mm (range 0.0–11.0 mm), respectively. RP size correlated positively with ureteral diameter in the
study population (P <0.0001), but not in group 1 when analyzed separately (P = 0.47). UO was secondary to stones
in 80 (70%) ureters. Seventeen (21%) cats had a positive urine culture. At admission, 79 (96%) cats were azotemic
with a median preoperative SCr concentration of 444 µmol/l (range 108–1326 μmol/l). The mean (95% confidence
interval [CI]) preoperative SCr concentration was significantly higher in group 1 (762 µmol/l [498–1165 μmol/l]) than
in group 2 (409 µmol/l [333–502 μmol/l]). RP size in the two groups correlated negatively with preoperative SCr
concentration (P = 0.0002).
Conclusions and relevance  Feline UO may be associated with minimal RP dilation and the severity of RP and
ureteral dilation can be highly variable. Absence of significant RP dilation does not rule out UO in cats.

Keywords: Ureteral obstruction; subcutaneous ureteral bypass; hydronephrosis; hydroureter; chronic kidney
disease; azotemia; renal pelvis dilation; antegrade pyelography; pyelectasia; ureteral dilation

Accepted: 29 November 2020

1Department of Clinical Sciences, Centre Hospitalier Universitaire

Introduction Vétérinaire (CHUV), Faculty of Veterinary Medicine, University
of Montreal, Saint-Hyacinthe, QC, Canada
Since the first case series of cats with ureterolithiasis was 2Faculty of Veterinary Medicine, University of Montreal,
published in 1998, feline ureteral obstruction (UO) has Saint-Hyacinthe, QC, Canada
been increasingly diagnosed and treated.1,2
Feline UO is a potentially life-threatening condition Corresponding author:
that may cause severe azotemia by decreasing renal blood Charles Lemieux DVM, Department of Clinical Sciences, Centre
Hospitalier Universitaire Vétérinaire (CHUV), Faculty of Veterinary
flow and glomerular filtration rate secondary to increased Medicine, University of Montreal, 1525 rue des Vétérinaires,
pressure within the renal pelvis (RP) and ureter. Cats with Saint-Hyacinthe, QC J2S 8H5, Canada
UO often suffer from concurrent kidney disease.3 Email: [email protected]
Lemieux et al 893

UO in cats most commonly occurs secondary to studies in cats with RP dilation as small as 2 mm, and
obstructive ureterolithiasis, which are mainly composed studies in humans, also reported this observation.2,16,22,23
of calcium oxalate.4–7 Obstructive ureterolithiasis is now Although the presence of RP dilation and dilated pelvic
recognized as the most frequent cause of acute kidney diverticula is an important ultrasonographic sign of UO,
injury in this species.4,8 Other causes of UO include it may fail to occur or occur later in the disease process.
acquired ureteral stricture, ureteritis, pyelonephritis/ Absence of significant RP dilation in feline UO may lead
pyonephrosis, ureteral neoplasia, blood clots, dried to a misdiagnosis and have important negative reper-
solidified blood calculi, congenital abnormalities (ure- cussions on the patient if left untreated. The degree of
teral stenosis with or without ectopia, circumcaval ure- RP dilation secondary to UO may reflect the degree and
ter), surgical trauma and retroperitoneal fibrosis.2,4,5,9–14 duration of outflow obstruction, urine output and renal
Ultrasonography is commonly used to assess cats tissue compliance against increased pressure within the
with azotemia. Findings such as RP dilation and ure- kidney.
teral dilation proximal to the location of obstruction are The main objective of this study was to describe RP
usually seen with UO and the underlying cause may be and ureteral ultrasonographic measurements in a popu-
identified. In other cases, such as with stricture or blood lation of cats with confirmed benign UO by antegrade
clot and dried solidified blood calculi, the cause of UO pyelography. The secondary objective was to further
may be difficult to identify on ultrasound.12,13 Diagnostic describe clinical findings associated with minimally
utility of ultrasonography may vary depending on the dilated obstructed kidneys in an attempt to better under-
cause of the UO, with a sensitivity and specificity of 98% stand its occurrence.
and 96%, respectively for detection of ureterolithiasis
and 44% and 98%, respectively for detection of ureteral Materials and methods
stricture.7 Ultrasonography was considered inaccurate to Case selection
diagnose feline UO in one study when using pyelogra- Medical records of cats treated by subcutaneous ureteral
phy as the gold standard, as no significant differences in bypass (SUB) device placement for partial or complete
ultrasonographic signs were found between cats with an unilateral or bilateral benign UO at the Centre Hospitalier
obstructed and non-obstructed ureter.15 In the study by Universitaire Vétérinaire of the University of Montreal,
Lamb et al, only 71% of cats with a tentative diagnosis of from January 2012 to December 2018 were reviewed.
UO, based on clinical data including ultrasound findings Cats were included in the study if they had an ini-
of the urinary tract, were shown to actually have a UO tial diagnosis of benign UO on abdominal ultrasound
using pyelography. based on the concurrent findings of RP dilation and
The RP of cats and dogs with normal renal func- ureteral dilation proximal to the location of obstruction
tion may be too small to measure ultrasonographically, and subsequently confirmed via antegrade pyelography.
although RP widths reaching almost 4 mm have been A fluoroscopic-guided antegrade pyelogram was per-
observed in both species.16,17 Diuresis or polyuria may formed intraoperatively by one of the authors (MD or
result in RP dilation in cats and dogs.16,18,19 The degree of CV) before each SUB device placement to confirm the UO.
RP dilation varies among cats with normal renal function After access to the RP was achieved with an 18 G over-
and those values may overlap with those observed in cats the-needle catheter, a urine sample was submitted for
with renal disease such as chronic kidney disease (CKD), aerobic bacterial culture and antimicrobial susceptibility
pyelonephritis or UO, thereby complicating its interpreta- testing. Fluoroscopic-guided antegrade pyelography was
tion.16,17 In two previous studies, RP dilation of >13 mm performed by injecting sterile saline (0.9% NaCl) mixed
was invariably attributed to UO, but the majority of the with iohexol (in equal proportions) into the RP so as to
obstructed kidneys had an RP dilation of <13 mm and achieve RP distension and ureteral filling. If a complete
there was overlap with other renal diseases.16,17 or partial UO was confirmed, a SUB device was placed
Renal diverticula and ureters in healthy dogs and cats in the obstructed kidney. A complete UO was defined
are barely distended by urine flow and therefore not nor- as RP and ureteral dilation up to an abrupt termination
mally visible during ultrasound examination.20 The lumi- of the contrast medium in the ureter associated with a
nal diameter of a non-obstructed distal feline ureter has complete lack of contrast medium distally. A partial UO
been reported to be approximately 0.4 mm; however, how was defined as RP and ureteral dilation up to an abrupt
this measurement was obtained is difficult to verify.21 The decrease in ureteral diameter associated with a delayed
ureters of 10 healthy control cats were evaluated ultra- transit of contrast medium into the urinary bladder.
sonographically and showed no measurable ureteral dila- To meet the inclusion criteria, an abdominal ultra-
tion.17 As with RP dilation, the degree of ureteral dilation sound examination had to be performed by a board-
may also overlap among cats with UO and other renal certified radiologist prior to antegrade pyelography.
diseases such as pyelonephritis.16,17 Ultrasound images were retrospectively reviewed by a
The authors have observed several cases of UO in cats board-certified radiologist when specific measurements
with minimal RP dilation and distended ureters. Previous of the RP in transverse plane and/or ureter were not
894 Journal of Feline Medicine and Surgery 23(10)

reported on the ultrasound report. Presence of pelvic distributions. An Anderson–Darling normality test was
diverticula dilation, defined by visible pelvic diverticula, used. Variation in RP size or ureteral diameter in rela-
were also reported on reviewed ultrasound images. For tion to several independent variables including group,
patients that underwent multiple abdominal ultrasound patient’s age, cause of UO, pelvic diverticula dilation and
examinations prior to surgery, the images acquired imme- urine culture result obtained by pyelocentesis were exam-
diately prior to surgery were selected for the study. When ined with a linear mixed model with animal identification
several measurements of the RP in transverse plane were as a random effect adjusting for unequal variances when
recorded during the same ultrasound examination, mean needed. A linear mixed model was also used to examine
RP size was calculated. the relationship between RP size and ureteral diameter.
Each obstructed kidney was divided into two groups: A Pearson’s correlation test was used to evaluate the
group 1 included small RP measurements of ⩽4 mm and relationship between RP size or ureteral diameter and
group 2 included larger RP measurements of >4 mm. This SCr concentration of unilaterally obstructed kidneys at
cut-off was selected by the authors based on RP width presentation and at discharge.
variations that can be seen in cats with normal renal func- The Cochran–Mantel–Haenszel χ2 test was used to
tion in order to better describe a population of cats with assess the difference of distribution of identified causes
benign UO associated with minimally dilated RP and to of UO and concurrent pelvic diverticula dilation between
simplify comparison with other variables.15 groups 1 and 2.
Cats were excluded from the study if malignant UO All analyses were performed with statistical software
was diagnosed, if no ultrasound examination was per- (SAS, version 9.3), and values of P <0.05 were considered
formed by a board-certified radiologist prior to antegrade statistically significant.
pyelography or if ultrasound measurements of RP and ure-
teral diameters were not available at the time of the study. Results
Cats
Medical records review A total of 82 cats were enrolled in the study, including
For each cat enrolled in the study, data extracted from the 32 (39%) cats with bilateral UO and 50 (61%) cats with
medical record included signalment, body weight, side unilateral UO: 29 (58%) were left sided and 21 (42%) were
of UO, urinary tract ultrasonographic findings including right sided. Five cats were excluded from the study; one
RP size in transverse plane and ureteral diameter of the had a malignant UO at the bladder trigone, two were
obstructed kidney, suspected cause of UO, presence of operated on after hours and ultrasound was performed
dilated pelvic diverticula, serum creatinine (SCr) concen- by an internist and two had nephroliths completely filling
tration upon arrival and at discharge date, urine culture the RP, preventing appropriate measurements. SUBs were
results and method of urine collection (intraoperative placed in all cats.
pyelocentesis and/or preoperative cystocentesis) and if The population consisted of 44 (54%) spayed female
antibiotics were given <24 h or >24 h before urine collec- cats and 38 (46%) castrated male cats with a median
tion were all recorded. age of 9.0 years (range 2.5–17.2 years) and body weight
SCr concentration at presentation to the hospital was of 4.06 kg (range 2.15–9.25 kg). There were 66 domes-
measured by a blood gas analyzer with a limit of detec- tic shorthair cats, six Siamese, two Abyssinian and one
tion of 1326 µmol/l. A cat was considered azotemic if SCr each of the following: Himalayan, Cornish Rex, Bengal,
concentration was ⩾140 µmol/l as recommended by the Balinese, Burmese, Persian, Tonkinese and Birman.
International Renal Interest Society.24 In the final study analysis, there was a total of 114
obstructed kidneys and ureters. Thirty (26%) kidneys
Statistical analysis were included in group 1 and presented with a small
In cases of bilateral UO, kidneys and associated ureters RP measurement ⩽4 mm and 84 (74%) were included in
were individually analyzed. group 2 and presented with a larger RP measurement
SCr concentration for cats with bilateral UO present- >4 mm. A total of nine (8%) obstructed kidneys had an
ing both a small RP measurement ⩽4 mm and a larger RP measurement ⩽2 mm.
RP measurement >4 mm was not taken into account dur-
ing comparison of this parameter between both groups, Ultrasound findings
given the simultaneous affiliation with the two groups. The median RP and ureteral diameters in the study
Only cats with unilateral UO were considered when population were 6.6 mm (range 1.1–37.0 mm) and
evaluating the relationship between RP size or ureteral 3.2 mm (range 0.0–11.0 mm), respectively. The median
diameter and SCr concentration. SCr concentration of cats ureteral diameter in group 1 and 2 were 2.5 mm (range
euthanized before discharge were not taken into account 1.0–11.0 mm) and 3.8 mm (range 0.0–11.0 mm), respec-
when evaluating SCr concentration at discharge. tively. When all obstructed kidneys and ureters were
Data for RP size, ureteral diameter and SCr con- considered, a statistically significant positive relation-
centration were log10-transformed to normalize the ship was identified between RP and ureteral diameters
Lemieux et al 895

(R2 = 58.9%, P <0.0001). However, no significant differ- UO (607 µmol/l [414–892 μmol/l]) than in unilateral UO

ence was found between these two variables in group 1 (349 µmol/l [277–440 μmol/l]) (P = 0.017). The mean (95%
when analyzed separately (P = 0.47). Information on CI) preoperative SCr concentration was significantly
renal diverticula (dilated or not) was reported in 67% and higher in group 1 (762 µmol/l [498–1165 μmol/l]) than
71% of obstructed kidneys in groups 1 and 2, respectively. in group 2 (409 µmol/l [333–502 μmol/l]) (P = 0.01). RP
Among them, pelvic diverticula dilation was present in size in the two groups correlated negatively with preop-
65% and 92% of obstructed kidneys in groups 1 and 2, erative SCr concentration (Pearson’s r = −0.52, P = 0.0002)
respectively. Mean RP size (95% confidence interval [CI]) but not with SCr concentration at discharge (Pearson’s
with and without concurrent pelvic diverticula dilation r = −0.13, P = 0.38). There was no significant correlation
were 8.3 mm (6.6–10.3 mm) and 3.5 mm (2.6–4.8 mm), between ureteral diameter and preoperative SCr concen-
respectively. RP size was significantly larger if concur- tration (Pearson’s r = −0.21, P = 0.16) or SCr concentration
rent pelvic diverticula dilation was present (P <0.0001). at discharge (Pearson’s r = −0.10, P = 0.50).
Ureteral diameter was not associated with pelvic diver- From the 81 cats for which an SCr concentration was
ticula dilation (P = 0.27). There was no significant asso- recorded, 78 (96%) were azotemic at admission and 64
ciation between RP size (P = 0.65) or ureteral diameter (79%) were azotemic on the day of discharge. The three
(P = 0.37) and the patient’s age. cats without azotemia at admission were included in
Of the 114 obstructed ureters, 80 (70%) were associated group 2. Two had a unilateral UO and one had a bilat-
with ureterolithiasis based on ultrasound examination, eral UO.
which included 18 (60%) ureters in group 1 and 62 (74%)
ureters in group 2. The prevalence of UO caused by uret- Urine culture and sensitivity
erolithiasis was not statistically different between the two Urine culture results from preoperative cystocentesis
groups (P = 0.56). For the remaining 34 obstructed ure- and intraoperative pyelocentesis were available for 48
ters, a specific etiology could not be identified on ultra- (59%) and 81 (99%) cats, respectively. A total of 42 (51%)
sound. A ureteral stricture or ureteritis was suspected in cats received antibiotics preoperatively: <24 h prior to
31 obstructed ureters. No etiology was identified in the surgery in 12 (29%) cats and >24 h prior to surgery in
remaining three obstructed ureters as their entire course 30 (71%) cats. Antibiotics used include beta-lactamases
could not be followed during the ultrasound examina- alone, fluoroquinolones alone or given together with
tion. Mean RP size (95% CI) associated and not associ- beta-lactamases in 12 (28%), 20 (48%) and 10 (24%) cats,
ated with UO caused by ureterolithiasis were 7.6 mm respectively. Among available pyelocentesis and cysto-
(6.3–9.2 mm) and 5.2 mm (3.9–6.9 mm), respectively. RP centesis urine samples, seven (9%) and 13 (27%) cultured
size was significantly larger in kidneys with UO caused positive, respectively. Seventeen of 82 (21%) cats had a
by ureterolithiasis compared with those without uretero- positive urine culture. Escherichia coli, Staphylococcus spe-
lithiasis (P = 0.023). Ureteral diameter was not associated cies and Enterococcus faecalis were isolated in 12 (70%),
with the occurrence of ureterolithiasis (P = 0.68). three (18%) and two (12%) cultures, respectively.
Results from both pyelocentesis and cystocentesis urine
Creatinine values cultures were available in 47 (57%) cats and were in agree-
The median SCr concentration of all cats with a UO was ment in 37 (79%) cats (34 negative cultures and three posi-
444 µmol/l (range 108–1326 μmol/l) preoperatively and tive cultures) and in disagreement in 10 (21%) cats. Nine
184 µmol/l (range 85–780 μmol/l) the day of discharge. urine cultures obtained by cystocentesis preoperatively
The mean SCr concentration at discharge (95% CI) did were positive while intraoperative urine cultures obtained
not differ between group 1 (210 µmol/l [156–282 μmol/l]) by pyelocentesis were negative. Among these patients,
and group 2 (197 µmol/l [173–226 μmol/l]) (P = 0.71). eight received antibiotics between the time of cystocente-
Five cats did not survive to discharge and were eutha- sis and pyelocentesis and one did not receive any antibiotic
nized. Among these, four had a bilateral UO and one therapy. One urine culture obtained by pyelocentesis intra-
had a unilateral UO. Ten cats with bilateral UO (31%) operatively was positive (E coli) while preoperative urine
were excluded from SCr concentration statistical analy- culture obtained by cystocentesis was negative.
sis between the two groups because they were present- The mean size (95% CI) of the RP was significantly
ing both a small and a larger RP. In group 1, the median larger in obstructed kidneys with positive urine culture
preoperative SCr concentration was 923 µmol/l (range obtained by pyelocentesis (13.9 mm [7.8–24.9 mm]) com-
141–1326 μmol/l) and the mean preoperative SCr con- pared with those with negative urine culture (6.4 mm
centration (95% CI) did not differ between cats with [5.5–7.5 mm]) (P = 0.013). Ureteral diameter was not asso-
bilateral (602 µmol/l [245–1326 μmol/l]) and unilateral ciated with urine culture results (P = 0.22).
UO (932 µmol/l [699–1243 μmol/l]) (P = 0.33). In group
2, the median preoperative SCr concentration was Discussion
361 µmol/l (range 108–1326 μmol/l) and the mean preop- This study revealed a large group of cats with con-
erative SCr concentration (95% CI) was higher in bilateral firmed benign UO associated with minimal RP dilation.
896 Journal of Feline Medicine and Surgery 23(10)

Twenty-six percent of kidneys had an RP diameter strictures on pyelography in comparison to ultrasound

<4 mm and 8% of kidneys had an RP diameter <2 mm. could not be determined in this retrospective study. Cats
Considering these results, UO, regardless of its severity, with a positive urine culture obtained by pyelocentesis
may be associated with minimal RP dilation that may not had significantly larger RP diameters suggesting that
differ from unobstructed cats or cats with other renal- pyelonephritis may have contributed to the UO; how-
related diseases. ever, these cats all had ureterolithiasis identified during
Ultrasonographic measurement of the RP alone may ultrasonography.
fail to correctly identify obstructed kidneys in cats and Despite the small RP, SUBs were successfully placed
therefore a UO cannot be excluded based on the absence in all patients (both nephrostomy and cystostomy cath-
of significant RP dilation. Previous studies have reported eters). In patients with a small RP preventing formation
this finding.2,17 Ultrasonographic ureteral dilation may of the nephrostomy catheter’s loop, nephrostomy tubes
help better assess UO in cats; however, absence of dila- were placed extending into the ureter and not looped.
tion of the ureter or a minimally dilated ureter may also In previous studies, bacteriuria was identified in
be associated with UO, especially if the obstruction is 25–33% of cases of feline UO.2,22 These studies were
at the ureteropelvic junction. The presence of ureteritis based on the microscopic examination of urine sediment
and/or fibrosis could also limit its distension. In cats or urine culture results by either cystocentesis or pyelo-
with suspected UO, RP and ureteral diameters should centesis. The lower prevalence of positive urine cultures
be evaluated by ultrasound and a search for the cause of in the present study (21%) may be explained by our diag-
obstruction should be undertaken. In cases with equivo- nostic criteria being based solely on urine culture from
cal ultrasound changes compatible with UO, antegrade urine samples obtained by pyelocentesis and cystocen-
pyelography may be considered to confirm or exclude tesis and the high prevalence of preoperative antibiotic
an obstruction. Antegrade pyelography is considered the therapy, often prescribed by the primary veterinarian.
most accurate test to diagnose and identify the site of The prevalence of urinary tract infection in the present
UO.9,25 In a retrospective study of 49 cats with a tentative study could be underestimated given that preoperative
diagnosis of UO based on ultrasonography undergoing urine culture results were not available in 41% of cats;
pyelography, only 71% of the 65 kidneys subjected to 51% of cats received a preoperative antibiotic and eight
pyelography were shown to have UO.15 In another recent cats had a positive urine culture by cystocentesis and a
study of 33 kidneys from cats and dogs that underwent negative urine culture by pyelocentesis after receiving
antegrade pyelography, 42% had a complete UO, 27% antibiotics. Bacterial isolates in this study are similar to
had a partial UO and 21% had functional UO.26 others previously described with E coli being the most
RP and ureteral diameters in cats with UO in this frequently isolated followed by Gram-positive cocci.
study were slightly lower than those reported previously. Urinary tract infection seems to be rather uncommon in
Previous studies reported a median maximal RP width of cats with UO compared with dogs in which over half of
11.5 mm (range 2.0–29.0 mm, n = 79), 9.2 mm (range 2.0– patients had a positive urine culture.27,28 Although 79%
35.5 mm, n = 186), 9.0 mm (range 3.0–30.0 mm, n = 46), of urine culture results by cystocentesis appeared to be
6.8 mm (range 1.2–39.1 mm, n = 17) and 10.4 mm (range consistent with those by pyelocentesis, this result may
3.1–19.3 mm, n = 11) and maximal median ureteral diam- be underestimated from the high prevalence of antibiot-
eter of 3.5 mm (range 1.0–11.0 mm, n= 79), 3.3 mm (range ics prescribed preoperatively. Urine cultures obtained by
0.0–10.0 mm, n = 172) and 3.7 mm (range 0.0–14.0 mm, cystocentesis were similar to urine cultures obtained by
n = 11) in cats with UO.2,15–17,22 The lower RP and ureteral pyelocentesis. Nevertheless, the authors recommend a
diameters in our study may be explained by a tendency to urine culture obtained by pyelocentesis when perform-
identify and treat UO more aggressively at our institution ing an antegrade pyelography or during intraoperative
or reflect a different population of cats with UO. SUB device placement in feline UO. One cat in this study
As reported previously, most of the UOs in our feline had a positive intraoperative urine culture obtained by
population were caused by ureterolithiasis. Other causes pyelocentesis while preoperative urine culture obtained
of UO were difficult to confirm on ultrasound examina- by cystocentesis was negative. The preoperative urine
tion. Considering the poor sensitivity of ultrasound in sample obtained by cystocentesis was taken 6 days prior
identifying ureteral stricture, many cats were suspected to surgery; therefore, a bacterial infection could have
to have a stricture.7 RP size was significantly larger in developed during this time.
kidneys with UO caused by ureterolithiasis compared Many factors may affect the degree of RP dilation in
with those without ureterolithiasis. Other causes of UO feline UO. The degree of hydronephrosis secondary to UO
less likely identified on ultrasound, such as ureteral stric- may reflect the degree and duration of outflow obstruc-
ture, ureteritis, pyelonephritis, blood clots or dried solidi- tion, urine output and renal tissue compliance against
fied blood calculi, may therefore cause a lesser degree increased pressure within the collecting system. Cats with
of obstruction. The degree of UO and ability to identify partial UO may have a small RP initially if the condition
Lemieux et al 897

is acute or if they are volume depleted during ultrasound used model to study the mechanisms of tubulointersti-
examination. RP dilation may be enhanced with adminis- tial fibrosis due to its rapid development together with
tration of high rates of fluids or diuretics.16,18,19,29 It is now tubular atrophy.38 Alternatively, CKD could play a role
well known that cats with CKD have a certain degree of in urolithiasis formation through abnormal handling of
interstitial inflammation and fibrosis and tubular atro- minerals and metabolites.34
phy that are more severe with advanced disease and This study, along with previous retrospective stud-
positively correlated with the severity of azotemia.30,31 ies, has shown that the vast majority of cats with benign
Renal parenchymal and/or capsular fibrosis associated UO are azotemic at admission regardless of whether the
with CKD could limit RP dilation and/or renomegaly obstruction is unilateral or bilateral.2,22 Another inter-
in an obstructed kidney owing to decreased compliance esting finding is that cats in group 1 had a significantly
of fibrotic tissue despite increased pressure within the higher SCr concentration at admission than cats in group
renal urine collection system.32 However, to the authors’ 2 and that RP size correlated negatively with preopera-
knowledge, this theory is not proven in veterinary medi- tive SCr concentration. This finding could be the result
cine and further prospective studies are needed to explore of more advanced CKD in group 1 with greater fibrosis
this hypothesis. Performing renal biopsies at the time of and less tissue compliance in these patients. However,
surgery or renal histology following death may aid in more controlled investigations are needed to explore this
determining the underlying process preventing RP dila- theory. Several parameters not controlled in this study
tion. However, as most patients are severely azotemic at could also have influenced RP and SCr concentration
the time of surgery, this is not routinely pursued. measurements. There was, however, no significant cor-
CKD is a frequent finding in cats with UO. Many of relation between RP size and SCr concentration at dis-
these cats have ultrasonographic evidence of CKD at charge. Explanations for this finding could be attributed
admission.4,5,15,33 Of the 46 kidneys with proven UO fol- to the small number of cats evaluated and the overall
lowing pyelography in a study of azotemic cats, 39% had improved azotemia following resolution of UO, resulting
ultrasonographic signs compatible with pre-existing CKD in less SCr concentration variation between cats.
including irregular kidney shape, cortical scars, reduced There was an absence of correlation between the diam-
kidney size and parenchymal calcification.15 In another eter of the RP and ureter in group 1 when analysed sepa-
study of 47 cats with ureterolithiasis, 94% of the affected rately compared with all kidneys. This finding is well
cats had ultrasonographic evidence of chronic changes illustrated in Figure 1, where minimal RP dilation is asso-
associated with kidney disease.33 Of the 117 cats that ciated with severe hydroureter secondary to obstructive
underwent ureteral surgery or ureteral stent placement ureterolithiasis. This could be explained by the presence
in one study, 73% had evidence of chronic renal changes of renal parenchymal and capsular fibrosis with variable
during ultrasound examination.5 In a study of 41 cats with fibrosis and inflammation of the ureter, thus limiting the
UO treated with a ureteral stent or a SUB device, 23 cats expansion of the RP and/or the ureter. Ureteral fibro-
(56%) had a known history of CKD of at least 6 months.3 sis secondary to UO has been shown in rats after iatro-
A positive association between urolithiasis and feline genic ureteral ligation.39 A similar process could occur
CKD has been reported.34 This study showed a signifi- in cats, therefore preventing ureteral dilation over time.
cantly higher prevalence of CKD among cats with upper While RP size was generally larger with concurrent pelvic
urinary tract urolithiasis (33/59 [56%]) than cats with- diverticula dilation, kidneys in group 1 often had dilated
out urolithiasis (20/67 [30%]). However, as no causal- pelvic diverticula. Limited RP expansion owing to fibro-
ity between urolithiases and CKD was assessed during sis with sustained pressure could result in dilated pelvic
the study, the authors conclude that it remains unclear diverticula.
whether urolithiasis is a predictive factor for, or a con- This study has a number of limitations, many of which
sequence of, CKD.34 Similar associations have also been are related to its retrospective nature. Lack of standardi-
identified in human medicine where the presence of uro- zation of ultrasound examinations and inter-radiologist
lithiasis, nephrolithiasis in particular, has been associ- variation could have affected RP and ureteral measure-
ated with a two-fold higher risk of development of CKD ments. Lack of prior information regarding the degree
independent of other known CKD risk factors.35–37 The of UO (complete or partial) is another important limita-
relationship between CKD and urolithiasis in veterinary tion of the present study. UO in the population of this
medicine remains unclear and requires further investi- study were all confirmed by one of the authors (MD or
gations. Although the exact mechanism of urolithiasis- CV) prior to SUB device placement based on the cri-
associated kidney damage is yet to be elucidated, several teria outlined in the ‘Materials and methods’ section.
pathways have been proposed, including intermittent Data regarding pelvic diverticula were only available
upper urinary tract obstruction and infection, renal in approximatively 70% of ultrasound reports in both
parenchymal mineral deposition, parenchymal inflam- groups, which could have contributed in overestimating
mation and fibrosis and renal injury from urolithiasis the number of dilated pelvic diverticula, especially in the
treatments.35 UO in rodents is considered the most widely first group where absence of pelvic diverticula dilation
898 Journal of Feline Medicine and Surgery 23(10)

median SCr concentration and therefore influenced com-

parison between unilateral and bilateral UO in group 1
and between both groups. Finally, the analyzer used to
measure SCr concentration had a maximum detection
limit of 1326 µmol/l, which limited the analysis of this
parameter. Given these uncontrolled variables, results
regarding RP diameter and SCr concentration should be
assessed cautiously.

Conclusions
The results of our study show that feline UO may be asso-
ciated with minimal RP dilation and the severity of RP
and ureteral dilation can be highly variable. Absence of
significant RP dilation does not rule out UO in cats and
attention to ureteral diameter and further examinations,
such as antegrade pyelography, may be considered to
confirm a UO in cases with equivocal ultrasonographic
changes. Early recognition and decompression are crucial
in these patients in order to preserve renal function as
much as possible. Further controlled prospective stud-
ies are needed to evaluate the pathophysiology behind
minimally RP dilation in feline UO.

Conflict of interest The authors declared no potential

conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding  The authors received no financial support for the

research, authorship, and/or publication of this article.

Ethical approval This work involved the use of non-

experimental animals only (including owned or unowned
animals and data from prospective or retrospective studies).
Established internationally recognized high standards (‘best
Figure 1  Ultrasound images of the left kidney and ureter practice’) of individual veterinary clinical patient care were fol-
(a,b) and lateral radiograph of the abdomen (c) of a cat with lowed. Ethical approval was therefore not specifically required
benign ureteral obstruction prior antegrade pyelography. for publication in JFMS.
Images (a,b) show minimal renal pelvis dilation (1.2 mm) and
a proximal ureteral dilation of 1.7 mm. As the ureter continues Informed consent  Informed consent (either verbal or writ-
caudally, there is an increase in its diameter up to 7.5 mm ten) was obtained from the owner or legal custodian of all
in its caudal portion up to a large ureterolith (measuring animal(s) described in this work (either experimental or non-
7.7 mm in length). Image (c) shows large ureteroliths in the experimental animals) for the procedure(s) undertaken (either
caudal ureter (dashed arrow) and several smaller ureteroliths prospective or retrospective studies). No animals or humans
throughout its course to the kidney (arrows) where nephroliths are identifiable within this publication, and therefore addi-
are also visible (arrowheads)
tional informed consent for publication was not required.

may not have been mentioned. Information regarding ORCID iD Charles Lemieux https://orcid.org/0000-
0002-1191-2262
patient hydration and prior medical history, the amount
of fluids administered prior to ultrasound examination,
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