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1. Pelvi-Ureteric Junction
Obstruction
Dr. Arjun A. Pawar
MBBS, MS,
M. Ch. Pediatric Surgery,
DNB Pediatric Surgery,
FMAS,
FIAGES.
Divine Pediatric Surgery Centre. i.
a. w.

2. Hydronephrosis- Aseptic dilatation of
pelvicalyceal system
SFU

3. UTD – Urinary tract dilatation

5. Causes of Antenatal Hydronephrosis

9. Introduction
Incidence - 1 in 1250 live births
M:F=2:1
PUJO- Adynamic segment
High grade vs Low grade
Intrinsic Vs Extrinsic

11. Etiology
Primary PUJO:
Intrinsic obstruction – Scarring of ureteric
valves
Ureteral hypoplasia- Inhibit the natural
peristaltic emptying
Abnormal or high insertion of the ureter
Crossing lower-pole renal vessel(s)
Renal ectopy
Renal Hypermobility
Secondary PUJO: Renal stone disease,
Failed repair,

12. Pathophysiology
Adynamic segment in upper ureter,
Obstructing lesions(Valves, Polyps)
Folds(Persistent Ostlings folds).
Complete obstruction- Rapid deterioration
of function
Partial obstruction- Gradual deterioration
of function

13. Clinical Presentation
Increasing prenatal
detection- 80%
Asymtomatic PUJO in infants
Abdominal lump
Abdominal pain
Urinary tract infection
Dietl’s crisis
Hematuria, Hypertension
Association with other
anomalies- Anorectal,
syndromes-MRKH

14. Evaluation
•Blood Ix: CBC, KFT, Urine, HIV, HbsAg,
•USG
•MCU
•IVP
•EC Scan/ MAG3 scan +- DMSA scan
•CT KUB scan
•MR Urography

15. Investigations: Ultrasonography
•Ideal screening tool
• Anteroposterior pelvic diameter (APPD)
• Cranio caudal diameter of pelvis
• Parenchymal thickness (UPPT, MPPT, LPPT)
• Bipolar renal length
• Kindney size
• Ureter
• Bladder
• Posterior urethra details
• RI- Kidney
•Limitations
•Operator dependant
•body habitus
•overlying bowel gas
•patient cooperation

16. USG
•The first postnatal USG 48 to 72
hrs after birth
•RI > 0.75 - obstruction requiring
surgery
•Sensitivity ~ 90 – 95%,
•Specificity ~ 85%

17. Diuretic Renogram
•Functional investigation:
99mTc-Diethylenetriaminepentaacetic acid (DTPA)
99mTc-Mercaptoacetyltriglycine (MAG3)
99mTc -Ethylene dicysteine (EC)
Radiopharmeceuti
cal
Renal Handling Application
DTPA GFR dependent
clearance
Renography
MAG3 Mainly by tubular
secretion
Renography
EC Tubular secretion Renography

18. Diuretic Renogram
Replaced IVP – negligible radiation
Sensitivity 100% and Specificity 94%
Objective assessment:
 Renal blood flow
Differential renal function
Intra renal transit time
Time taken for radioisotope washout from
the pelvicalyceal system (t½)
Follow-up and postoperative assessment

20. Diuretic Renogram
The “Well – Tempered”
renogram – standard
practice and comparable
results
 Hydration
 Bladder catheter
 Furosemide injection
– F0/F15 protocol
First Renogram
 EC - 4 Wks of Age
 MAG3- 15 days

21. Magnetic Resonance Urography
•MR renography (Gd – DTPA)
Anatomic and functional
assessment
•Selective usage- anatomical
anomalies- Duplex, ectopia,
malrotation

22. Indications for Pyeloplasty
Differential renal function below
40%
Decrease in DRF > 5% on subsequent
renal scintigraphy scan
T ½ max - >20 min
Recurrent urinary tract infections
Rapid aggravation of hydronephrosis
Severe bilateral hydronephrosis due
to PUJO

23. Indications for Pyeloplasty
•DOCUMENTED OBSTRUCTION on
nuclear imaging irrespective of
DRF and grade of hydronephrosis
•Equivocal - regular and close follow
up

24. Types of Pyeloplasty
Three types:
The intubated type
The flap types
The dismembered type

25. Intubated pyeloplasty
•Long segments of
narrowing of ureter
•Contraindicated in
aberrant lower polar
artery
•Higher fibrosis and
restenosis rates
•Long term success rates -
50 – 88 %

26. Flap Repairs
•Pelvic flaps without sacrificing ureteropelvic
continuity- for Small extra renal pelvis
Foley Y – V plasty
Culp – DeWeerd spiral flap
Scardinho – Prince vertical flap
• Rarely performed and have specific indications

27. Dismembered pyeloplasty
Modified Anderson Hynes Pyeloplasty
for PUJ obstruction
Excision of redundant pelvis
Excision of pathological PUJ segment
Spatulated wide ureteropelvic anastomosis
Dependent
Water tight
Tension free anastomosis

28. Dismembered pyeloplasty – Principles

29. Approaches
Open Surgery:
Flank Approach
Dorsal Lumbotomy Approach
Anterior Subcostal Approach
Laparoscopic Surgery:
Transperitoneal approach
Retroperitoneal approach
Robotic assisted Surgery:

34. Complications and Outcome
Bleeding and infection
Prolonged urinary extravasation
Perirenal Urinoma
Urosepsis
D-J stent migration
Delayed opening of the anastomosis
Anastomotic stricture

35. SPECIAL SITUATIONS

36. PUJ and polar vessels
•Often a surprise
•Rarely associated
with intrinsic PUJ
obstruction
•Pyelopyelostomy
•A-H Pyeloplasty

37. PUJ and VUJ obstruction
•The saline flush test for distal patency
•Missed VUJ obstruction – large low pelvis
•DJ stent / nephrostomy till VUJ is addressed
(Ureteric reimplantation )

38. PUJ obstruction and VUR
•10% PUJO – concurrent reflux
•Routine MCU
Bilateral HDN
Ureteric dilatation on preop USG
• Dilated ureter at operation
• Pyeloplasty - post op MCU / DMSA
• Manage VUR on merits

39. Secondary PUJ with VUR

40. Poorly functioning kidney
• ? nephrectomy for split
function < 10%
•Has potential for recovery –
younger child
•Preoperative DMSA/PCN
•Split renal Cr clearance

41. Duplex kidney
•Obstruction may be seen in either unit
•Diagnosis usually on radionuclide scan
•MCU /IVP/MRU
•AH pyeloplasty
•Pyeloureterostomy

42. Horseshoe Kidney
•Largely asymptomatic
•Significant obstruction –
dismembered
pyeloplasty
•Laparoscopic / Robotic –
good results