Long term outcomes following pyeloplasty for unilateral pelviureteric junction obstruction in paediatric patients

Background: Pelviureteric junction obstruction (PUJO) is the most common cause of pediatric hydronephrosis. The gold standard treatment for PUJO is Anderson hynes (AH) dismembered pyeloplasty. The parameters to assess the post-operative outcomes of pyeloplasty include reduction in the AP diameter of the pelvis and increase in parenchymal thickness. The aim of the study was to find out the long-term outcomes following pyeloplasty for Ureteropelvic junction obstruction (UPJO) in paediatric patients.Methods: A prospective study was done from September, 2014 to January, 2019. All children above the age of 2 months who presented with unilateral PUJO were included in the study. All patients underwent ultrasound of the kidneys and diuretic renogram. All patients underwent AH dismembered pyeloplasty. Success was defined as both symptomatic relief and radiographic resolution of obstruction at the last follow-up visit.Results: 60 patients with unilateral intrinsic PUJO were included in this study. Post-operatively split renal function (SRF) improved in 42 patients, remained stable in 13, and deteriorated in 5 cases. Post-operative renal drainage improved in 40 patients, remained stable in 15 and deteriorated in 5. The degree of hydronephrosis deteriorated in 5 cases but improved or was preserved in 55 cases. The renal parenchyma deteriorated in 7 cases. Overall success rate of AH dismembered pyeloplasty was 92%.Conclusions: Dismembered pyeloplasty is a safe and effective treatment of PUJO in the pediatric population. Majority of the patients had an improved split renal function, renal drainage, cortical thickness, and decreased degree of hydronephrosis.

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.

Endoscopic balloon dilatation of primary obstructive megaureter: method standardization and predictive prognostic factors

The management of congenital primary obstructive megaureter (POM) is usually conservative, especially during the first year of life. Endoscopic high-pressure balloon dilatation (EHPBD) is indicated when symptoms, increasing dilatation and progressive renal damage are recorded, particularly in children younger than one year of age. We identified and described endoscopic prognostic factors predicting the success or failure of endoscopic dilatation. Thirty-eight patients (33 M;5 F) with POM from 2005-2018 were included. Diagnosis was based on US distal ureter dilatation (>7 mm), obstructive MAG-3 diuretic renogram and absence of vesicoureteral reflux (cystography). 24 patients were under 1 year of age. All patients underwent cystoscopy and high-pressure balloon dilatation with 3,5 Fr dilating balloon, after ascending pyelography. Median follow-up was of 6.5 years. We identified characteristics with poor prognosis: stenotic punctiform ureteral ostium and/or ostium located in a bladder diverticulum (9 pts) and stenotic tract longer than 1 cm (5 pts). The patients with a stenotic tract shorter than 1 cm (18 pts) were divided into two groups: <5 mm (5 pts) and between 5 and 10 mm (13 pts) showed a good response to dilatation. Endoscopic evaluation of ureteral ostium with pneumatic dilatation when possible is a useful diagnostic and therapeutic solution for POM treatment, especially under one year of age. EHPBD is effective in short stenotic tracts (<5 mm). It may also be repeated with good results in intermediate stenotic sections (5 mm-1 cm). According to our preliminary results, the procedure is more effective if performed earlier (3-7 months of life). Greater cohort and longer follow-up are needed to verify the stability of these results.

Complicated Urinary Tract Tuberculosis in a 13-Year-Old Adolescent with Chronic Kidney Disease and Antituberculous Drug-Induced Hepatotoxicity

Urinary tract tuberculosis (TB) is a rare extrapulmonary manifestation of TB in children. The disease is potentially underdiagnosed because it clinically resembles other urinary tract infections. A 13-year-old adolescent girl presented with pain, difficulty in micturition, and gross hematuria for almost two years before admission, and she had left flank pain since one year ago and significant loss of body weight during the illness. The close TB contact was her grandmother who was on TB treatment. Acid-fast bacilli yielded positive result, Mantoux test was positive (17 mm), urine GeneXpert MTB/Rif was positive; tuberculoma was identified on kidney histopathology, and a diuretic renogram revealed an uncorrected glomerular filtration rate (GFR) of the right and left kidney to be 32.5 mL/min/1.73 m2 and 5 mL/min/1.73 m2, respectively. During the treatment, oral anti-TB drug-induced hepatotoxicity (ADIH) occurred to the patient. This problem was solved with management according to the British Thoracic Society (BTS) guidelines. Screening TB in children is very important for a better outcome. If children complain of some complicated urinary tract infection, TB should be suspected. Optimaly treating children with urinary tract TB exagerrated with ADIH and CKD is very challenging.

Clinical profile and outcome of pelvi-ureteric junction obstruction (PUJO) in children presenting above 1 year

Background: Pelvi-ureteric junction obstruction (PUJO) is defined as anatomical or functional obstruction to the flow of urine from the pelvis to the upper ureter. With the advent of ultrasonography most of the cases of PUJO are identified in antenatal period. The treatment protocol for antenatal diagnosed PUJO is standardized. Few children present later in life. Present study was done to evaluate clinical profile and outcome of children presenting with PUJO above 1 year.Methods: A retrospective observational study conducted by the department of Paediatric Surgery, KIMS hospital Bangalore. All children with PUJO above 1 year of age from January 2015 to January 2018 were included. Clinical, biochemical and imaging findings of these children were tabulated. A diuretic renogram was done to confirm the diagnosis. The children underwent either pyeloplasty or nephrectomy, depending on the function of the kidney. In children with calculi, pyelolithotomy with pyeloplasty was done. The children were followed up post-surgery.Results: Twenty-six children were included in the study. Mean age of presentation was 6.86±4.13years. Most common presentation was pain abdomen. Left kidney was commonly involved. The mean anteroposterior pelvic dimension (APPD) of involved kidney was 38.96±17.7 mm. 5 children presented with poorly functioning kidney with split renal function less than 10%. In three children PUJO was associated with pelvic calculi. Out of the 26 children simple nephrectomy was required in 4 (15%) children. The remaining 22 children underwent pyeloplasty. Mean duration of stay was 6.19±1.8 days. Post-pyeloplasty diuretic renogram showed improved drainage with improved function.Conclusions: PUJO is common cause of urinary obstruction in children. Delay in diagnosis or presentation leads to increased chances of renal damage and loss. Hence it is important to diagnose PUJ obstruction at the earliest and receive prompt treatment.