How successful is the conservative management of pelvi-ureteric junction obstruction in adults?

Case Report; Concomitant Left Nutcracker Syndrome and Right Ureteropelvic Junction Obstruction

We report rare case of concomitant left nutcracker syndrome and right ureteropelvic junction obstruction (UPJO) on adult female patient diagnosed by CT urogram after she presented with intermittent bilateral flank pain. For this we did Anderson-Hynes pyeloplasty for right ureteropelvic obstruction, it was laparoscopic initially but due to difficulty of stenting it is changed to open. She had smooth post-op course then discharged on 3rd post-op day. Symptoms of nutcracker syndrome are not that much bothersome for the patient so we planned to follow her conservatively.

Progressive Ureteropelvic Junction Obstruction and Renal Function Deterioration in Adult, Even in a Short Period of Time

Introduction

The ureteropelvic junction obstruction is more common in children; however, it can also affect adults. The management of this condition has shifted toward a nonoperative approach with serial ultrasonography and renography. Case Presentation. The ureteropelvic junction obstruction imaging with significant renal function deterioration in an adult patient is described in this report. Laparoscopic exploration revealed aberrant vessels that compress the ureteropelvic junction against the lower pole of the kidney.

Conclusion

It is important to consider that some of the ureteropelvic junction obstruction cases can get worse even in a short period of time.

Comments on a case of ureteropelvic junction obstruction with late progression in an adult female

INTRODUCTION

Ureteropelvic junction obstruction is a pathology typically diagnosed in childhood. Nevertheless, some clinically silent cases may be unnoticed until adulthood.

CASE DESCRIPTION

We report the case of a 53-year-old female with hydronephrosis due to ureteropelvic junction stenosis diagnosed in the adulthood, who subsequently developed obstruction with progressive worsening of renal function without symptoms.

CONCLUSION

The natural history of ureteropelvic junction obstruction is still obscure. Diuretic renogram is the gold standard for diagnosis and follow-up of ureteropelvic junction obstruction, but is weak in predicting the evolution of the disease, especially in patients with vague symptoms. Conservative treatment of adult patient with equivocal ureteropelvic junction obstruction seems reasonable, but requires a close clinical follow-up and strict patient compliance in order to promptly identify significant obstruction.

Does relative renal function improve after intervention for chronic ureteric obstruction?

Introduction

Unilateral renal function often deteriorates with chronic ureteric obstruction. Our objectives were to determine the change in relative renal function (RRF) by MAG3 renography after intervention for ureteric obstruction, and to identify clinical/epidemiological factors which influence long-term outcomes.

Material and methods

We identified 228 patients from 2006 to 2017 who underwent MAG3 renography before and after intervention for unilateral ureteric obstruction. Patients were grouped into categories preoperatively - with normal RRF (43–57%) through mild (29–42%), moderate (15–28%) and severe (<15%) impairment of RRF. Patient demographics, types of obstructive uropathy and intervention employed were analysed. Each group was assessed for the absolute change in RRF and change in RRF category postoperatively.

Results

The mean patient age was 50.4 years (SD 16.7), and 62.3% were female. Overall, the mean pre- and post-intervention RRF of the obstructed kidney did not differ significantly (32.30% vs. 32.20%, P = 0.835). Most patients remained in their preoperative RRF group: 85.9% of normal, 67.4% of mild, 64.4% of moderate and 73.3% of patients with severe RRF impairment did not change category.

Patients with mildly impaired preoperative RRF showed a significant worsening postoperatively (36.37% vs. 34.58%, P = 0.024). The other three groups showed no significant change in RRF following intervention.

Multivariate logistic regression analysis showed no statistically significant association between type of intervention, age, gender or diagnosis and improvement in postoperative RRF category.

Conclusions

Our results show that RRF does not improve significantly after intervention for ureteric obstruction. The aim should therefore be to maintain existing renal function and relieve symptoms.

Cortical transit time: understanding utility and pitfalls in children with pelviureteric junction obstruction

INTRODUCTION

Delayed cortical transit time (CTT) has been recently studied and proposed as a parameter that can predict the need for surgery in children with pelviureteric junction obstruction (PUJO).

AIM

The aim of this study was to study the change in CTT, after surgery, in children with PUJO and to correlate CTT with intrapelvic pressure of the kidney.

MATERIAL AND METHODS

A prospective study was performed, and all children who underwent pyeloplasty from January 2016 to December 2017 were included. Pre-operative and postoperative renal ultrasonography and Technetium-99m mercaptoacetyltriglycerine Tc-MAG3 renal scintigraphy were performed. Cortical transit time was measured by a visual method by two different observers. The renal intrapelvic pressure of the kidney was also measured during surgery after giving a diuretic to replicate the diuresis induced during the renal scan. The correlation was studied between the pre-operative CTT and intrapelvic pressures and between the pre-operative CTT and the renal function of the affected kidney.

RESULTS

Thirty-one children were included in the study. The median age of children who underwent surgery was 50 months (2-168). In 71% of patients, the CTT was prolonged before surgery, whereas only 22.5% had delayed CTT after surgery. The mean CTT before surgery was 226.1 ± 74.8 s and decreased to 165.4 ± 55.9 s after surgery (p= <0.001). The mean intrapelvic pressure was 21 ± 7.5 cm H₂O. There was no correlation noted between the intrapelvic pressure and the CTT. A significant negative correlation was noted between the CTT and the different renal function of the kidney.

DISCUSSION

This is the first prospective study that studies the changes in CTT after surgery. Only retrospective studies had been conducted to date which concluded that CTT was delayed in most of the patients who had been operated. It has been proposed that the prolonged CTT is due to raised pressure in the kidney secondary to obstruction. This study did not find any correlation between the pressure and CTT. The significant negative correlation between CTT and renal function also emphasizes the need to take the renal function into consideration before interpreting and using the absolute value of CTT for guiding treatment.

CONCLUSION

Cortical transit time assessment by the visual method is a useful parameter in the management of children with PUJO. There is a significant improvement in CTT after surgery.

Diuretic Enhanced Ultrasonography in the Diagnosis of Pyeloureteral Obstruction

Background and Objectives: To determine the value of diuretic ultrasonography for the diagnosis of obstructive hydronephrosis. Materials and Methods: Diuretic enhanced ultrasonography was used routinely as a part of examination of patients with hydronephrosis in our Department. There were 72 patients (42 males, 30 females; aged 2 months to 17 years; median age 7.07 years) with a sonoscopic diagnosis of hydronephrosis included from January 2006 until October 2011. The anteroposterior diameter (AD) of renal pelvis was measured sonoscopically before and at sixty minutes after furosemide injection. A weight-adjusted dose of 1 mg/kg of furosemide was administered intravenously. Results: Patients were operated on if pyeloureteral obstruction was suspected because of low or deteriorating differential renal function, increasing hydronephrosis or symptoms thereof. Hydronephrosis was unilateral in 61 (84.7%) and bilateral in 11 (15.3%) patients. The median AD of pelvis before furosemide injection was 22 mm in operated and 17 mm in non-operated patients (p = 0.005). Sixty minutes after furosemide injection, the AD of pelvis in operated patients was 35.5 mm and 25.8 mm in non-operated—25.8 mm (p < 0.001). Logistic regression model demonstrated that significant factors for surgery were: AD 60 min after furosemide infection and ultrasonographic parenchymal sclerosis. Conclusion: Ultrasound measurement of the AD of renal pelvis 1 h after the injection of furosemide used as an additional investigation can help in predicting obstructive hydronephrosis.

Conservative management of pelvi-ureteric junction obstruction (PUJO): is it appropriate and if so what duration of follow-up is needed?

OBJECTIVE

• To establish whether it is safe to manage minimally symptomatic and asymptomatic pelvi-ureteric junction obstruction (PUJO) conservatively.

PATIENTS AND METHODS

• In all, 50 patients with PUJO diagnosed with dynamic renography, and monitored with at least two renograms.

RESULTS

• In all, 19 patients were totally asymptomatic, while 31 patients had minimal symptoms at time of diagnosis. • The mean follow-up was 53 months. • During the course of follow-up 10 of the 50 patients deteriorated. • All patients who had asymptomatic renographic deterioration, deteriorated within 2 years of diagnosis. • Eight of the 10 patients that deteriorated needed pyeloplasty and two nephrectomy.

CONCLUSIONS

• Conservative management of patients with minimally symptomatic and asymptomatic PUJO is safe. • Discharging patients could be considered at 2 years from diagnosis, if they remain renographically stable and asymptomatic or minimally symptomatic.

Relative renal function does not improve after relieving chronic renal obstruction

Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Technetium-99m MAG3 renography can be used to quantify relative renal function (RRF). Deterioration of renal function occurs with chronic obstruction. Small studies have previously shown that RRF is not improved in adult patients after pyeloplasty. Some studies have suggested that patients with higher preoperative RRF are more likely to improve. To our knowledge, these data represent the largest review of cases related to this subject. This study verifies past studies' assertions that RRF does not improve after relief of chronic renal obstruction. Using multivariable analysis, we identify lower age and lower preoperative RRF as predictors of >7% improvement in RRF. These data suggest that the aim of relieving obstruction should be to maintain RRF and alleviate symptoms, but not to seek improvement in overall renal function.

OBJECTIVE

To determine the change in relative renal function (RRF) after relief of chronic obstruction in adults.

PATIENTS AND METHODS

We retrospectively identified 85 adult patients who underwent scintigraphic diuretic renography before and after an intervention to relieve chronic unilateral renal obstruction. Patients were stratified into groups of low (<20%), medium (20-40%) and high (>40%) preoperative RRF in the obstructed kidney. Each group was assessed for change in RRF after relief of obstruction. We performed multivariable logistic regression analysis to determine whether age and pre-procedural RRF predicted a >7% improvement in RRF, controlling for medical comorbidities and type of obstruction.

RESULTS

The mean (sd) patient age was 43.6 (16.8) years and 66% of patients were female. The mean (sd) pre- and postoperative RRF values were not significantly different (37.6 [12.3] % vs 38.4 [13.6] %; P = 0.31). Patients stratified by low, medium and high preoperative function showed no significant change in postoperative RRF (P = 0.53, 0.39 and 0.77, respectively). In multivariable logistic regression analysis, younger age (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.83-0.98) and lower preoperative RRF (OR 0.90, 95% CI 0.83-0.97) predicted improvement in RRF of >7%, after adjustment.

CONCLUSIONS

RRF does not significantly increase after relief of chronic obstruction. The goals of relieving chronic renal obstruction should be to maintain renal function and relieve symptoms, but not to regain renal function.

Unilateral anomalies of kidney development: why is left not right?

Abnormal renal development results in congenital anomalies of the kidney and urinary tract. As many studies suggest that renal malformations are more often found on the left side, a meta-analysis was performed on the distribution of five different unilateral anomalies: multicystic dysplastic kidney, renal agenesis/aplasia, renal ectopia, pelviureteral junction obstruction, and non-obstructive non-refluxing megaureter. Of these anomalies, the left side was affected in 53%, 57%, 56.9%, 63.2%, and 62.5% of patients, respectively, significantly different when compared with an anticipated 50% of left-sided anomalies. An exception to this left-side predominance was found in females with combined genital anomalies and unilateral renal agenesis that commonly present on the right side. The exact mechanisms leading to these lateralizations remain to be determined but may involve vascular development, differential gene expression, or susceptibility to environmental factors such as hypoxia. This remains largely speculative, however, illustrating our limited knowledge of embryogenesis in general and nephrogenesis in particular.

Robotic management of complicated ureteropelvic junction obstruction

PURPOSE

To assess the feasibility and outcomes of robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO).

METHODS

Complicated UPJO cases included patients with the following: concomitant multiple or calyceal stones, secondary UPJO (post-ureteroscopy, open or percutaneous surgery), malrotated kidney, horseshoe kidney, ectopic kidney, giant hydronephrosis, poorly functioning kidney (glomerular filtration rate <20 ml/min), non-redundant renal calyces (requiring nephroplication), ptosis of the kidney (requiring nephropexy), long stricture (>2 cm), age <5 or >60 years and duplex pelvis. All cases underwent dismembered robotic pyeloplasty. Data were collected for operative time, blood loss, stone clearance, analgesic usage and time to recovery. Follow-up was done with intravenous urography and dynamic renal scan.

RESULTS

A total of 29 cases underwent dismembered robotic pyeloplasty with an average operative time and blood loss of 130 min and 50 ml. Stone clearance could be achieved in 8 out of 10. The average follow-up period was 15 months with a symptomatic and objective success rate of 96.6% (28/29). No perioperative complications were noted.

CONCLUSIONS

Robotic pyeloplasty for complicated cases of UPJO is feasible, safe and effective, and has a durable success rate.