Managing Ureteropelvic Junction Obstruction in the Young Infant

Abstract

In the last decade, management of congenital UPJ obstruction has become progressively observational despite the lack of precise predictors of outcome. While it is clear that many children will have resolution of their hydronephrosis and healthy kidneys, it is equally clear that there are those in whom renal functional development is at risk. Surgical intervention for the young infant, under 6 months, has become relatively infrequent, yet can be necessary and poses unique challenges. This review will address the clinical evaluation of UPJO in the very young infant and approaches to determining in whom surgical intervention may be preferable, as well as surgical considerations for the small infant. There are some clinical scenarios where the need for intervention is readily apparent, such as the solitary kidney or in child with infection. In others, a careful evaluation and discussion with the family must be undertaken to identify the most appropriate course of care. Further, while minimally invasive pyeloplasty has become commonly performed, it is often withheld from those under 6 months. This review will discuss the key elements of that practice and offer a perspective of where minimally invasive pyeloplasty is of value in the small infant. The modern pediatric urologist must be aware of the various possible clinical situations that may be present with UPJO and feel comfortable in their decision-making and surgical care. Simply delaying an intervention until a child is bigger may not always be the best approach.

Diminished Systemic Amino Acids Metabolome and Lipid Peroxidation in Ureteropelvic Junction Obstruction (UPJO) Infants Requiring Surgery

“…Since hydronephrosis is a common finding in prenatal ultrasound, and even if imaging techniques successfully detect asymptomatic cases, the emergent question of progression to severe renal impairment remains crucial for pediatric patient stratification and management [ 7 ].…”

“…Obstructive hydronephrosis, predominantly arising from UPJO, may result in chronic kidney disease (CKD) in children [ 25 ]. Longstanding complications of renal damage may appear later, in young adulthood, and by that time, noxious effects of renal development could have happened [ 7 ]. The modern era of minimally invasive approaches intensifies the need to discover reliable and sensitive diagnostic and prognostic biomarkers for the most effective and refined treatment of UPJO patients.…”

“…Longitudinal measures of common clinical parameters may serve in the prediction of progression of CKD from obstructive uropathy (OU) at an age-specific baseline [ 34 ]. Metabolomics and proteomics studies have also contributed to both serum and urinary [ 7 , 8 , 9 , 10 , 35 , 36 , 37 ] biomarkers’ pool, but they still have not been established in clinical practice.…”

“…Findings from already published studies regarding biomarkers and their utility in hydronephrosis management are often conflicting, and none of them has been incorporated in regular clinical practice to date [ 7 ]. Most experts conclude that further multi-disciplinary and multi-institutional studies are needed in order to identify a marker or a panel of markers that could reliably identify obstructed renal units that are at risk of deterioration [ 7 , 8 ].…”

Association between severity of prenatally diagnosed hydronephrosis and receipt of surgical intervention postnatally among patients seen at a fetal-maternal center

“…While current literature indicates that a large proportion of cases are stabilized or resolved following conservative management [ 1 , 3 , 6 ], studies have reported differing findings regarding the proportion of patients who go on to require surgery. A recent review found that the rate of complete resolution of prenatally-detected HN in the absence of surgery may range from 33 to 70% [ 7 ]. Discrepancies in the rates of patients who require surgery may be largely due to differences in HN severity between populations [ 8 – 13 ].…”