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UPJ Obstruction Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD

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Presentation on theme: "UPJ Obstruction Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD"— Presentation transcript:

1 UPJ Obstruction Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD
Dominic Frimberger, MD University of Oklahoma Department of Urology Section of Pediatric Urology

2 UPJ Obstruction Most common site of urinary tract obstruction in children Majority are discovered antenatally 1: pregnancies 80% antenatal hydronephrosis 2:1 boys:girls 2/3 on the left 10-40% bilateral

3 Etiology Unknown Intrinsic lesion with the ureteropelvic wall
Inefficient drainage through an aperistaltic segment Overdistention of the pelvis leads to hypertrophy and decreased GFR If high grade obstruction, penal parenchymal changes and impaired function result Histology shows loss of normal smooth muscle, hypertrophy, and fibrosis Less commonly: valvular mucosal folds, persistant fetal convolutions, upper ureteral polyps

4 Etiology Extrinsic compression by an aberrant accessory or early branching vessel to the lower pole 15-52% of the cases in children Most common cause in adults Secondary UPJ obstruction Severe VUR or lower urinary tract obstruction permanent kink at the UPJ due to tortuosity high inserting ureter

5 Associated Anomalies Another urologic abnormality-50%
Contralateral UPJ 10-40% Renal dysplasia, aplasia, MCKD VUR up to 40% Found in 21% of VATER patients

6 Presentation Historically presented as a palpable mass Newborn
Antenatal hydronephrosis 80% UTI, hematuria, failure to thrive, feeding difficulties, sepsis, azotemia Later in life 30% diagnosed after UTI 25% diagnosed after hematuria Episodic abdominal pain and vomiting due to intermittent obstruction

7 Diagnosis Most are diagnosed antenatally
Hydronephrosis on prenatal ultrasound Most are asymptomatic at birth The major question: Is the obstruction clinically significant? Radiologic evaluation helps to determine this, however there is no perfect way to diagnose obstruction

8 Diagnosis Renal U/S Doppler U/S 1st study performed in the neonate
Lacks specificity to determine significance Doppler U/S Tests Resistive Index Increases sensitivity and specificity of U/S RI > 0.7 may be significant Wide range of variability limits this test

9 Diagnosis Diuretic Renal Scan Standardized protocol in children
IVF - 15cc/kg NS 30 minutes prior to study Catheterization Measure urine output every 10 minutes Renogram acquisition for 20 minutes or until pelvis full Lasix 1 mg/kg Diuresis renogram acquisition for 20 minutes Gives good differential function and drainage pattern

10 Diagnosis Disadvantages Variable response to Lasix
Variable timing of Lasix administration Variable renal pelvic compliance Do not correlate well with pressure-flow studies Not as helpful with equivocal results

11 Diagnosis IVP Retrograde pyelograms functional study
usually wait until 4 wks. Old pelviectasis after drainage Retrograde pyelograms mainly in cases of non-functioning kidneys can r/o distal obstruction

12 Diagnosis Pressure-flow (Whitaker)
fill pelvis at 10ml/min normal saline difference between pelvis and bladder invasive questionable accuracy if compliant pelvis injection at non-physiologic rates obstruction if pressure difference > cm

13 Follow-up U/S on day 2 - 3 of life Persistent hydronephrosis
VCUG to evaluate PUV or VUR Prophylactic antibiotics if VUR present No PUV or VUR - repeat U/S and diuretic renal scan at 1 month Continued hydro - surgery vs. observation observation - U/S and/or renal scan every 3-4 months for 1 year and then every 4-6 months surgery - open/endopyelotomy/laparoscopy

14 Conservative Management
Principles: 50% of antenatal hydro resolved postpartum unable to accurately diagnose true obstruction observations that asymptomatic hydronephrosis can resolve spontaneously Studies with infants with renal function >35-40% in the affected kidney and variable washout patterns “Rule of 1/3” - 1/3 stay the same, 1/3 improve, 1/3 worsen

15 Indications for Surgical Intervention
Presence of symptoms associated with the obstruction Impairment of overall renal function Progressive impairment of ipsilateral function Development of stones or infection Hypertension

16 Surgical Management Open Pyeloplasty Gold Standard
Dismembered pyeloplasty is the most common removal of stenotic or adynamic segment proximal ureter is mobilized, spatulated posteriorlaterally reanastomosed to the pelvis pelvic reduction may be necessary is large and redundant stent or nephrostomy tube if desired Foley for 24 hours ( if VUR present) Penrose for days Prevents urinoma formation % success rate

17 Dismembered Pyeloplasty

18 Surgical Options Foley V-Y-Plasty Good for 1-2 cm obstruction
Best for high inserting ureter Best with relatively small pelvis

19 Foley Y-V-Plasty

20 Surgical Options Spiral flap
Good for long obstructions (better in adults) Length of flap limited only by size of pelvis (keep length: width at 3:1) good when UPJ angle > 90

21 Spiral Flap

22 Surgical Management Endopyelotomy Antegrade or retrograde
Cold knife or electric current Acucise is very popular dilation balloon with hot wire 86% success in adults Slightly less effective in children Direct vision antegrade approach is most common retrograde less useful due to small ureteral caliber primary success % secondary success % less successful if associated with a crossing vessel

23 Surgical Management Laparoscopic pyeloplasty
Same indications as open or endourologic procedures Dismembered pyeloplasty is most common procedure performed Without crossing vessels, may do any number of flap procedures Up to 94% success rate, similar to open pyeloplasty

24 Conclusions More children are diagnosed with antenatal U/S
Current diagnostic tests do not differentiate between kidneys that will need surgery and those that will improve spontaneously Solitary kidney, bilateral UPJ, or poorly functioning kidneys should be considered for earlier surgery

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