The document discusses pelvi-ureteric junction obstruction (PUJO), detailing causes, clinical presentations, diagnostics, and treatment options such as pyeloplasty. It highlights the importance of timely evaluation and various imaging techniques for accurate diagnosis and follow-up. Surgical techniques, including different types of pyeloplasty, are explored along with their associated complications and management in special circumstances.

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