Results Of A Practical Protocol For Management Of Prenatally Detected Hydronephrosis Due To Ureteropelvic Junction Obstruction

Main Category: Urology / Nephrology
Article Date: 02 Feb 2009 - 4:00 PDT

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UroToday.com - Prenatally diagnosed hydronephrosis leading to ureteropelvic junction obstruction poses a dilemma to diagnostic management as to decide which of these children would end up needing surgery. Many invasive tests are performed to help delineate which children are at risk from the obstruction. MAG-3 renography, as well as MR urography and VCUG scanning, are typically done in these children along with ultrasonography.

A study by Dr. Ibrahim Karnak et al. reviewed 143 patients with the diagnosis of congenital ureteropelvic junction obstruction. They focused on their protocol of surveillance and selective utilization of renal scans after standardizing a protocol.

It appears that, as per their protocol, all the patients were initially evaluated with ultrasound, voiding cystourethrogram, and renal scans. Successive follow up was done only with ultrasonography. Repeat renal scans were reserved for those with worsening hydronephrosis or those that failed to improve by one year of age.

The records of 143 patients and a total of 198 renal units (RU) were reviewed. The male to female ratio was 2.7. UPJO was unilateral in 88 (61%) patients and occurred more frequently on the left side (68%). Obstruction was bilateral in 55 (39%) patients. 178 RU (90%) were followed conservatively, while open dismembered pyeloplasty was the initial therapeutic approach in 20 RU (10%). The mean age at the time of surgery was 15.95 +/- 14.60 weeks (range 2-60). Postoperative course was uneventful during 33.43 +/- 33.53 months (range 2-120) with favorable US and RFS results. In conservatively managed patients, mean follow-up time was 14.94 +/- 14.35 months (range 1.5-142). Spontaneous resolution of hydronephrosis was observed in 87 RU (49%), while 10 RU (5.6%) eventually required surgery for worsening appearance or function on US or RFS, respectively (n = 8), symptom development (n = 3), and/or parental preference due to persistently prolonged T ((1/2)) (n = 4). Seventy-two RU (40.4%) remain under surveillance, with improvement (47.2%) or stable hydronephrosis (47.2%) in 94.4%. Decreased DRF occurred in 1 RU. Nine RU (5%) were lost to follow-up. With their algorithm, only 12% of patients underwent 2 or more RFS.

The group concluded that the majority of ureteropelvic junction obstructions can be managed conservatively. Spontaneous resolution of the hydronephrosis was encountered, and 87% of those were conservatively managed. Their algorithm is not different than was what is commonly practiced. If there is a renal bladder ultrasound which shows pelvicaliectasis, moderate to severe in nature, then a renal scan or MR urography is warranted. Conversely, if there is pelviectasis without caliectasis one can follow these children quite easily since there is negligible pressure on the kidney if you have pelviectasis without caliectasis. In my opinion, the true take home message of this study is that we have to be able to identify this 13% of children that require surgery upfront so we can save the whole group from follow-up and invasive studies.

Karnak I, Woo LL, Shah SN, Sirajuddin A, Ross JH
Pediatr Surg Int. 2009 Jan;25(1):61-7.
10.1007/s00383-008-2294-6

Written by UroToday.com Medical Editor Pasquale Casale, MD

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