1. Case 2
7 year old girl
Hydronephrosis diagnosed at the age of 4, regular follow up at Dr.邱’s OPD
The initial presentation was abdominal pain and nausea/vomting.
Prenatal ultrasound: no significant finding
At 2014
Renal echo
Right moderate hydronephrosis, with the Antero-posterior diameter of renal pelvis around 3.34 cm
No hydroureter was noted
At 2015
Right mild hydronephrosis, with the A-P diameter around 0.83cm, SFU grading 1

2. Case 2
At 2016
Abdominal pain and vomiting condition got gradually severe
Renal echo
Right severe hydronephrosis, SFU grading IV
No hydroureter
Suspect UPJ-obstruction
Admission for workup

4. Case 2 8/31 Right PCN insertion Right 24hr urine Ccr: 44(from PCN)
Left 24 hr urine Ccr: 74(self-voiding)

5. Hospitalization course
VCUG, 9/5
1. Right vesicoureteric reflux grade, at least III.
2. Suspect right simple ureterocele.
3. Suspicious right sided UPJ stenosis, S/P PCN inserted.

6. Hospitalization course
CRFT diuretic renogram:
obstruction in the right collecting system with relatively low renal function (left and right renal function is 72.4% and 27.6%)
No obstruction in the left collecting system

7. Hospitalization course
Anterograde pyelogram
Right UPJ stenosis with hydronephrosis.
High-grade obstruction with only scanty of contrast meidum flow downward

8. Case 2 Diagnosis Scheduled for operation today
VU reflux combined with UPJ obstruction
10% of patients with severe vesicoureteral reflux, UPJ obstruction exists (or develops).
Secondary scarring in the presence of highgrade vesicoureteral reflux
UTI, s/p Antibiotics treatment
Scheduled for operation today

9. Vesicoureteral reflux
Primary(Most common):
Due to incompetent or inadequate closure of the ureterovesical junction (UVJ)
Secondary:
abnormally high pressure in the bladder(posterior urethral valves)
posterior urethral valves(Neurogenic bladder)

10. Vesicoureteral reflux
Clinical presentation
Prenatally found
Postnatal UTI episode
Diagnosis: VCUG
Management
In the majority of cases with primary VUR, especially those with low-grade reflux, there is spontaneous resolution
Conservative treatment in mild VUR patients

11. Vesicoureteral reflux
Surgical correction is considered and discussed with the family for children with the following conditions.
Grade IV/V reflux in children older than two or three years of age with persistent high-grade reflux or who have breakthrough infection.
Children who fail medical therapy and have breakthrough infections, who have significant side effects from continuous prophylactic antibiotic coverage, or whose families are not compliant with a long-term medical regimen.
Complications
Recurrent UTI episode
Renal scarring

12. Case 1
Case
Diagnosis
UPJ obstruction
VU reflux with UPJ obstruction
Cause
Congenital
Maybe acquired form(renal scarring)
Age of diagnosis
Prenatally found
4y/o
Initial presentation
No symptoms yet
Abdominal pain
nausea/vomiting
Renal echo
Severe hydronephrosis, grade 4
Severe hydronephrosis, Grade 4
VCUG
No VUR
At least grade III VUR
CRFT(comprehensive renal function test)
Obstruction in the left collecting system
Obstruction in the right collecting system
Anterograde pyelogram
UPG obstruction

13. Thank you!