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UPJ Obstuction
Dr.Perviz Hajiyev
uroloq.com
2016
uroloq.com
Epidemiology
‣ 1 in 500 live births screened by routine antenatal ultrasound.
‣ Male>Female
‣ Left>Right
‣ 10-40 % Bilateral
‣ Most common anatomical cause of antenatal hydronephrosis.
uroloq.com
Etiology
Usually caused by intrinsic stenosis of the proximal ureter at that UP
junction, and less commonly by extrinsic compression (accessory renal
artery) of the UPJ
uroloq.com
Etiology
‣ Intrinsic obstruction — an embryologic disruption of the proximal
ureter that alters circular musculature development and/or collagen
fibers, and composition between and around the muscular cells.
‣ Extrinsic obstruction — 10% of pediatric UPJ obstruction
‣ usually refers an aberrant lower-pole crossing vessels. 5% of HN
detected by prenatal screening. 30-70% of children presenting
later with symptomatic intermittent UPJ obstruction. (p.s. lower
pole vessels might induce secondary intrinsic stenosis)
‣ fibrous bands adhesions,ureteric folds and kinks in a normal
calibre UPJ, more frequent in older children with symptomatic UPJ
uroloq.com
Etiology
‣ Goals in diagnosing and treating UPJ:
- Prevent ipsilateral renal function loss(primary goal)
- fUTI
- Pain
- Hematuria
- Urolithiasis
uroloq.com
Diagnosis
Ultrasonography
‣ The most sensitive time for foetal urinary tract evaluation is the 28th week
‣ If dilatation is detected, US should focus on:
- laterality, severity of dilatation, and echogenicity of the kidneys;
- hydronephrosis or hydro-ureteronephrosis;
- bladder volume and bladder emptying;
- sex of the child;
- amniotic fluid volume
‣ Pelvic AP diameter
- >7 mm at 18-23 weeks gestation
- >10 mm during last trimester
- >12 mm at birth
should be considered as abnormal
‣ In older children with abdominal pain and suspected UPJ obstruction, an
ultrasound examination should be performed during the acute painful episode
(Dietl's crisis) to demonstrate hydronephrosis
uroloq.com
Diagnosis
Resistive index
‣ Resistive index is measured by the use of a Doppler ultrasound probe directed at
a branch of the renal artery. Measurement of resistive index is not a sufficiently
sensitive measure of obstruction to serve any useful role in clinical practice.
Voiding Cystourethrogram (VCUG)
‣ In newborns with identified UUT dilatation, the primary or important associated
factors that must be detected include:
- vesicoureteral reflux (16-25% of affected children);
- urethral valves;
- ureteroceles;
- diverticula;
- neurogenic bladder.
‣ Conventional VCUG is the method of choice for primary diagnostic procedures
uroloq.com
Diagnosis
MAG3
‣ In general, diuretic renography can be performed after six weeks of life
because immediate surgical intervention is rarely required
‣ Tubular agent, with high protein binging, high tubular extraction, and low
distribution in the extra-vascular space
‣ may also provide an estimate of the absolute renal function, although much
less reliable than a glomerular filtration rate study using 51Cr-EDTA
‣ DMSA renal scan provides a more accurate evaluation of the differantial
renal function especially with poorly functioning kidneys (irradiation dose
higher) DRF: DMSA>MAG3>DTPA
‣ Good drainage on renography is surely a define sign of the absence of
obstruction
uroloq.com
Diagnosis
MRI
‣ Advantage of MRI is the ability to discern accurate anatomy defining the point
of obstruction. MRI can also determine the split function of the kidney and
simulate the diuretic renogram by providing washout data.
‣ The disadvantage of MRI is the cost and need for sedation or general
anesthesia after 6 moths of age
Antegrade pyelogram
‣ is rarely necassary but may helpful to show exact level of obstruction is some
confusing cases
Pressure-flow studies
‣ Whitaker; percutaneous nephrostomy, infusion of extrensic flow (10 ml/mn)
and monitoring of intrapelvic pressures.
‣ invasive, required anesthesia
uroloq.com
Evaluation Unilateral	fetal	HN	
PA>12	mm,	3rd	tr	US
Prophylac<c	ab:	
oral	amoxicilin	(25	mg/kg/day)
Birthyes no
No	postnatal	evalua<on	required
PA	>	10	mm
repeat usg
yes
Stop	prophylac<c		ab,		
no	further	work-up
VCUG	
Evidence	of	VUR
no
Evalua<on	and	Management		
of	VUR
PA>	15	mm
no
yes
yes
no Stop	ab,	Repeat	US	aTer	3	
months
Diurethic	renography	
Evidence	of	obstruc<on
yes
Consider	Surgical	Correc<on
Monitor	using	imaging	studies
no
UpToDate, 2016
uroloq.com
Management
Unilateral	fetal	HN	
Diurethic	renography	
Evidence	of	obstruc<on
IMPAIRED		
Differen<al	Renal	Func<on	
(DRF)
DRF<	40%
DRF<	10-15%
Pyeloplasty
US	at	3	months	postop	
US+MAG-3	at	12	months	postop
Repeat	MAG-3	at	
9-12	months
DRF	improved DRF	Low
Follow-up
Nephrectomy	
(if	sympt./comp.)
uroloq.com
Management
‣ Symptomatic obstruction (recurrent flank pain, UTI) requires surgical correction
using a pyeloplasty, according to the standardised open technique of Hynes and
Anderson
‣ Indications for surgical intervention
- impaired split renal function (< 40%),
- a decrease of split renal function of > 10% in subsequent studies,
- poor drainage function after the administration of furosemide,
- increased anteroposterior diameter on US, and grade III and IV dilatation as
defined by the SFU
‣ In those kidneys where the differential function is less than 10%, a temporary
nephrostomy tube or double-J stent placement may allow for differentiating
kidneys with recoverable function from those with irreversible damage
uroloq.com
Management
Approach
‣ In the child, however, where the back muscles are less well developed an anterior
extraperitoneal approach or a dorsal lumbotomy incision.
‣ Lumbotomy approach in infants and younger children.
‣ Flank approach with mobilization of the kidney for older patients.
‣ In a redo pyeloplasty, the anterior transperitoneal approach is preferred.
‣ Anterior extraperitoneal approach:
- incision from the edge of the rectus muscle to just below the tip of the
12th rib.
- each muscle layer encountered is split in the direction of the muscle fibers
until the surgeon defines Gerota’s fascia by sweeping the peritoneum
medially.
- the fascia is then incised posterior to the lateral aspect of the kidney.
- the renal pelvis is identified by medial retraction of the peritoneum and
uroloq.com
Management
Approach
‣ Lumbotomy approach:
- A transverse skin incision, which follows Langer’s lines to avoid
postoperative spreading of the scar, is made with subsequent mobilization
of the skin before a vertical incision through the lumbodorsal fascia allows
the surgeon direct access to the renal pelvis.
- The closure is in one layer, which shortens operative time.
- In the case of bilateral UPJ obstruction, the surgeon may approach both
sides without repositioning the patient.
- The lumbotomy approach is contraindicated if one is dealing with an
incompletely rotated anterior renal pelvis.
- If the obstructed pelvis is mostly intrarenal, small or high, then a
lumbotomy approach may be more difficult
uroloq.com
Management
Approach
‣ Flank approach:
- Incision is made anterior to the tip of the 12th rib, or if necessary, a
supracostal.
- Both the external oblique and latissimus dorsi muscles are divided.
- Internal oblique and serratus posterior inferior muscles are divided.
- A transversalis muscle is often thin and can be separated with digital
dissection.
- The peritoneum is identified and retracted medially.
- Gerota’s fascia is then encountered and opened longitudinally to gain
exposure to the perinephric space.
uroloq.com
Management
Pyeloplasty
‣ The Foley Y–V plasty
- for the correction of UPJ with a high ureteral insertion
‣ Culp–DeWeerd spiral flap ureteropelvioplasty
- to bridge the gap between the pelvis and healthy ureter over a distance of
several centimeters
‣ Scardino–Prince vertical flap pyeloureteroplasty
- in a situation of a dependent UPJ with a large, square-shaped extrarenal
Tpelvis
‣ Anderson–Hynes dismembered pyeloplasty
Hitch Procedure
- Transposition of lower pole vessels
uroloq.com
Management
Anderson–Hynes dismembered pyeloplasty
uroloq.com
Management
Foley Y–V plasty
Culp–DeWeerd spiral flap ureteropelvioplasty
uroloq.com
Management
Non-operative management
‣ If a functional study reveals and confirms adequate ureteral drainage,
conservative management is the best option.
‣ Initially, low-dose prophylactic antibiotics within the first year of life are
recommended for the prevention of UTIs, although there are no existing
prospective randomised trials evaluating the benefit of this regimen.
uroloq.com
Notes
‣ Unless there is prompt relief of obstruction, loss of approximately 50% of
functioning nephrons after 6 days and the irreversible loss of all renal function
within 6 weeks. The timescale of renal damage is rapidly accelerated by the
presence of urinary infection (pyonephrosis).
‣ Extent of hydronephrosis (HN) by either SFU grade or anterior-posterior (AP)
diameter does not correlate with renal function.
‣ To our knowledge, no study demonstrates that prolonged drainage determined
by T1/2, appearance of the curve, or other measurement correlates with renal
func- tion or predicts future renal function loss.
‣ Most patients have <10 % change in ipsilateral renal function after pyeloplasty.
‣ Zero to 39 % of patients observed without surgery have ipsilateral function loss
variously described as >5 %, >10 %, or <40 %, but following pyeloplasty, final
ipsilateral renal function loss is 0–6 %.
uroloq.com
Notes
‣ No RCT shows benefit for surgery over observation to preserve ipsilateral renal
function.
‣ Two studies reported resolution of renal colic after surgery.
‣ No studies were found documenting impact of pyeloplasty on recurrent UTI,
hematuria, or renal stone formation.
‣ Two retrospective series reported symptomatic UPJO with differential function
<10 % initially managed by nephrostomy for 4–6 weeks. Improved function to a
mean ≥30 % occurred in 70 and 100 %.
‣ Only one series reported nephrostomy drainage for function <10 % in prenatally
detected (asymptomatic) UPJO in nine kidneys; only two had improved function
(19 and 41 %).
uroloq.com
Notes
‣ There was no difference in reported surgical success rates or complications
between open, laparoscopic, and robotic pyeloplasty.
‣ Laparoscopic surgery was associated with greater double-J stent use.
‣ Meta-analysis found operative times less with open surgery, and hospitalization
less with laparoscopic and robotic surgery.
‣ Two studies using patient questionnaires reported increased satisfaction with
incisions from robotic versus open renal surgery.
‣ Endopyelotomy was reported successful in from approximately 80 to 95 % of
cases.
‣ One retrospective comparison of reoperative pyeloplasty versus endopyelotomy
found reoperation significantly more successful, 100 % versus 39 %.
uroloq.com
Sources
‣ EAU Paediatric Urology Guidelines 2016
‣ ESPU Paediatric Web Book 2015
‣ Pediatric Urology Evidence for Optimal Patient Management 2013
‣ Essentials of Paediatric Urology 2nd Edition 2008
‣ The Kelalis–King–Belman Textbook of Clinical Pediatric Urology 2007
‣ Pediatric Surgery P.Puri 2006

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Ureteropelvic Junction (UPJ) Obstruction

  • 2. uroloq.com Epidemiology ‣ 1 in 500 live births screened by routine antenatal ultrasound. ‣ Male>Female ‣ Left>Right ‣ 10-40 % Bilateral ‣ Most common anatomical cause of antenatal hydronephrosis.
  • 3. uroloq.com Etiology Usually caused by intrinsic stenosis of the proximal ureter at that UP junction, and less commonly by extrinsic compression (accessory renal artery) of the UPJ
  • 4. uroloq.com Etiology ‣ Intrinsic obstruction — an embryologic disruption of the proximal ureter that alters circular musculature development and/or collagen fibers, and composition between and around the muscular cells. ‣ Extrinsic obstruction — 10% of pediatric UPJ obstruction ‣ usually refers an aberrant lower-pole crossing vessels. 5% of HN detected by prenatal screening. 30-70% of children presenting later with symptomatic intermittent UPJ obstruction. (p.s. lower pole vessels might induce secondary intrinsic stenosis) ‣ fibrous bands adhesions,ureteric folds and kinks in a normal calibre UPJ, more frequent in older children with symptomatic UPJ
  • 5. uroloq.com Etiology ‣ Goals in diagnosing and treating UPJ: - Prevent ipsilateral renal function loss(primary goal) - fUTI - Pain - Hematuria - Urolithiasis
  • 6. uroloq.com Diagnosis Ultrasonography ‣ The most sensitive time for foetal urinary tract evaluation is the 28th week ‣ If dilatation is detected, US should focus on: - laterality, severity of dilatation, and echogenicity of the kidneys; - hydronephrosis or hydro-ureteronephrosis; - bladder volume and bladder emptying; - sex of the child; - amniotic fluid volume ‣ Pelvic AP diameter - >7 mm at 18-23 weeks gestation - >10 mm during last trimester - >12 mm at birth should be considered as abnormal ‣ In older children with abdominal pain and suspected UPJ obstruction, an ultrasound examination should be performed during the acute painful episode (Dietl's crisis) to demonstrate hydronephrosis
  • 7. uroloq.com Diagnosis Resistive index ‣ Resistive index is measured by the use of a Doppler ultrasound probe directed at a branch of the renal artery. Measurement of resistive index is not a sufficiently sensitive measure of obstruction to serve any useful role in clinical practice. Voiding Cystourethrogram (VCUG) ‣ In newborns with identified UUT dilatation, the primary or important associated factors that must be detected include: - vesicoureteral reflux (16-25% of affected children); - urethral valves; - ureteroceles; - diverticula; - neurogenic bladder. ‣ Conventional VCUG is the method of choice for primary diagnostic procedures
  • 8. uroloq.com Diagnosis MAG3 ‣ In general, diuretic renography can be performed after six weeks of life because immediate surgical intervention is rarely required ‣ Tubular agent, with high protein binging, high tubular extraction, and low distribution in the extra-vascular space ‣ may also provide an estimate of the absolute renal function, although much less reliable than a glomerular filtration rate study using 51Cr-EDTA ‣ DMSA renal scan provides a more accurate evaluation of the differantial renal function especially with poorly functioning kidneys (irradiation dose higher) DRF: DMSA>MAG3>DTPA ‣ Good drainage on renography is surely a define sign of the absence of obstruction
  • 9. uroloq.com Diagnosis MRI ‣ Advantage of MRI is the ability to discern accurate anatomy defining the point of obstruction. MRI can also determine the split function of the kidney and simulate the diuretic renogram by providing washout data. ‣ The disadvantage of MRI is the cost and need for sedation or general anesthesia after 6 moths of age Antegrade pyelogram ‣ is rarely necassary but may helpful to show exact level of obstruction is some confusing cases Pressure-flow studies ‣ Whitaker; percutaneous nephrostomy, infusion of extrensic flow (10 ml/mn) and monitoring of intrapelvic pressures. ‣ invasive, required anesthesia
  • 10. uroloq.com Evaluation Unilateral fetal HN PA>12 mm, 3rd tr US Prophylac<c ab: oral amoxicilin (25 mg/kg/day) Birthyes no No postnatal evalua<on required PA > 10 mm repeat usg yes Stop prophylac<c ab, no further work-up VCUG Evidence of VUR no Evalua<on and Management of VUR PA> 15 mm no yes yes no Stop ab, Repeat US aTer 3 months Diurethic renography Evidence of obstruc<on yes Consider Surgical Correc<on Monitor using imaging studies no UpToDate, 2016
  • 12. uroloq.com Management ‣ Symptomatic obstruction (recurrent flank pain, UTI) requires surgical correction using a pyeloplasty, according to the standardised open technique of Hynes and Anderson ‣ Indications for surgical intervention - impaired split renal function (< 40%), - a decrease of split renal function of > 10% in subsequent studies, - poor drainage function after the administration of furosemide, - increased anteroposterior diameter on US, and grade III and IV dilatation as defined by the SFU ‣ In those kidneys where the differential function is less than 10%, a temporary nephrostomy tube or double-J stent placement may allow for differentiating kidneys with recoverable function from those with irreversible damage
  • 13. uroloq.com Management Approach ‣ In the child, however, where the back muscles are less well developed an anterior extraperitoneal approach or a dorsal lumbotomy incision. ‣ Lumbotomy approach in infants and younger children. ‣ Flank approach with mobilization of the kidney for older patients. ‣ In a redo pyeloplasty, the anterior transperitoneal approach is preferred. ‣ Anterior extraperitoneal approach: - incision from the edge of the rectus muscle to just below the tip of the 12th rib. - each muscle layer encountered is split in the direction of the muscle fibers until the surgeon defines Gerota’s fascia by sweeping the peritoneum medially. - the fascia is then incised posterior to the lateral aspect of the kidney. - the renal pelvis is identified by medial retraction of the peritoneum and
  • 14. uroloq.com Management Approach ‣ Lumbotomy approach: - A transverse skin incision, which follows Langer’s lines to avoid postoperative spreading of the scar, is made with subsequent mobilization of the skin before a vertical incision through the lumbodorsal fascia allows the surgeon direct access to the renal pelvis. - The closure is in one layer, which shortens operative time. - In the case of bilateral UPJ obstruction, the surgeon may approach both sides without repositioning the patient. - The lumbotomy approach is contraindicated if one is dealing with an incompletely rotated anterior renal pelvis. - If the obstructed pelvis is mostly intrarenal, small or high, then a lumbotomy approach may be more difficult
  • 15. uroloq.com Management Approach ‣ Flank approach: - Incision is made anterior to the tip of the 12th rib, or if necessary, a supracostal. - Both the external oblique and latissimus dorsi muscles are divided. - Internal oblique and serratus posterior inferior muscles are divided. - A transversalis muscle is often thin and can be separated with digital dissection. - The peritoneum is identified and retracted medially. - Gerota’s fascia is then encountered and opened longitudinally to gain exposure to the perinephric space.
  • 16. uroloq.com Management Pyeloplasty ‣ The Foley Y–V plasty - for the correction of UPJ with a high ureteral insertion ‣ Culp–DeWeerd spiral flap ureteropelvioplasty - to bridge the gap between the pelvis and healthy ureter over a distance of several centimeters ‣ Scardino–Prince vertical flap pyeloureteroplasty - in a situation of a dependent UPJ with a large, square-shaped extrarenal Tpelvis ‣ Anderson–Hynes dismembered pyeloplasty Hitch Procedure - Transposition of lower pole vessels
  • 19. uroloq.com Management Non-operative management ‣ If a functional study reveals and confirms adequate ureteral drainage, conservative management is the best option. ‣ Initially, low-dose prophylactic antibiotics within the first year of life are recommended for the prevention of UTIs, although there are no existing prospective randomised trials evaluating the benefit of this regimen.
  • 20. uroloq.com Notes ‣ Unless there is prompt relief of obstruction, loss of approximately 50% of functioning nephrons after 6 days and the irreversible loss of all renal function within 6 weeks. The timescale of renal damage is rapidly accelerated by the presence of urinary infection (pyonephrosis). ‣ Extent of hydronephrosis (HN) by either SFU grade or anterior-posterior (AP) diameter does not correlate with renal function. ‣ To our knowledge, no study demonstrates that prolonged drainage determined by T1/2, appearance of the curve, or other measurement correlates with renal func- tion or predicts future renal function loss. ‣ Most patients have <10 % change in ipsilateral renal function after pyeloplasty. ‣ Zero to 39 % of patients observed without surgery have ipsilateral function loss variously described as >5 %, >10 %, or <40 %, but following pyeloplasty, final ipsilateral renal function loss is 0–6 %.
  • 21. uroloq.com Notes ‣ No RCT shows benefit for surgery over observation to preserve ipsilateral renal function. ‣ Two studies reported resolution of renal colic after surgery. ‣ No studies were found documenting impact of pyeloplasty on recurrent UTI, hematuria, or renal stone formation. ‣ Two retrospective series reported symptomatic UPJO with differential function <10 % initially managed by nephrostomy for 4–6 weeks. Improved function to a mean ≥30 % occurred in 70 and 100 %. ‣ Only one series reported nephrostomy drainage for function <10 % in prenatally detected (asymptomatic) UPJO in nine kidneys; only two had improved function (19 and 41 %).
  • 22. uroloq.com Notes ‣ There was no difference in reported surgical success rates or complications between open, laparoscopic, and robotic pyeloplasty. ‣ Laparoscopic surgery was associated with greater double-J stent use. ‣ Meta-analysis found operative times less with open surgery, and hospitalization less with laparoscopic and robotic surgery. ‣ Two studies using patient questionnaires reported increased satisfaction with incisions from robotic versus open renal surgery. ‣ Endopyelotomy was reported successful in from approximately 80 to 95 % of cases. ‣ One retrospective comparison of reoperative pyeloplasty versus endopyelotomy found reoperation significantly more successful, 100 % versus 39 %.
  • 23. uroloq.com Sources ‣ EAU Paediatric Urology Guidelines 2016 ‣ ESPU Paediatric Web Book 2015 ‣ Pediatric Urology Evidence for Optimal Patient Management 2013 ‣ Essentials of Paediatric Urology 2nd Edition 2008 ‣ The Kelalis–King–Belman Textbook of Clinical Pediatric Urology 2007 ‣ Pediatric Surgery P.Puri 2006