Rapid onset renal deterioration in an adult with silent ureteropelvic junction obstruction

Pelvic ureteric junction obstruction: Natural history, nephrological considerations and current evidence base for surgical management in poorer functioning kidneys

Pelvic ureteric junction obstruction (PUJO) can pose a management challenge to urologists. The natural history of the disease, particularly in adults is poorly understood and management decisions are largely based on historical, poor quality data. Additionally, many older patients may already have a degree of renal impairment secondary to systemic disease, further compounding the situation. The purpose of this paper is to detail the pathophysiology and natural history of PUJO, discuss the implications of chronic kidney disease in this population detailing the current evidence base for poorer functioning kidneys and describe the nephrological advantages of accurate renal function testing. There exists accurate methods to assess both glomerular filtration rate (GFR) and split function which could potentially provide both the urologist and patient with more relevant data on which to base their decisions when contemplating surgical intervention. The existing, low patient number case series currently published fail to address the relevance of overall GFR on the outcomes after pyeloplasty, no studies use single unit GFR and there is no clear consensus on what constitutes surgical success. PUJO is an area of benign upper tract disease that is in need of high-quality scientific studies to identify when intervention is necessary, long-term success of both surgery and conservative management in poorer functioning kidneys and clear guidelines for urologists.