Outcome of Percutaneous Nephrostomy in Children With Ureteropelvic Junction Obstruction

Abstract

Introduction and objectives: Congenital ureteropelvic junction obstruction (UPJO) is the most common cause of hydronephrosis. Management protocols are based on the presence of symptoms and when the patient is asymptomatic the function of the affected kidney determines the line of treatment. Percutaneous nephrostomy (PCN) became a widely accepted procedure in children in the 1990s. The aim of the study was to evaluate the results of performing percutaneous nephrostomy (PCN) in all patients with UPJO and split renal function (SRF) of less than 10% in the affected kidney, because the management of such cases is still under debate.
 Methods:This prospective clinical trial was carried out at Dhaka Medical College Hospital from January 2014 to December 2016. Eighteen consecutive patients who underwent PCN for the treatment of unilateral UPJO were evaluated prospectively. In these children, ultrasonography was used for puncture and catheter insertion. Local anesthesia with sedation or general anesthesia was used for puncture. Pig tail catheters were employed. The PCN remained in situ for at least 4 weeks, during which patients received low-dose cephalosporin prophylaxis. Repeat renography was done after 4 weeks. When there was no significant improvement in split renal function (10% or greater) and PCN drainage (greater than 200 ml per day) then nephrectomies were performed otherwise pyeloplasties were performed. The patients were followed up after pyeloplasty with renograms at 3 months and 6 months post operatively.
 Results: All the patients had severe hydronephrosis during diagnosis and 14 patients with unilateral UPJO were improved after PCN drainage and underwent pyeloplasty. The rest four patients that did not show improvement in the SRF and total volume of urine output underwent nephrectomy. In the patients with unilateral UPJO who improved after PCN drainage, the SRF was increased to 26.4% ±8.6% (mean± SD) after four weeks and pyeloplasty was performed. At three and six months follow-up, SRF value was 29.2% ±8.5% and 30.8.2% ±8.8% respectively.
 Conclusion: Before planning of nephrectomy in poorly functioning kidneys (SRF < 10%) due to congenital UPJO, PCN drainage should be done to asses improvement of renal function.
 Bangladesh Journal of Urology, Vol. 20, No. 2, July 2017 p.61-64

Pyelo-ureteral junction obstruction in poorly functioning kidneys: Does conservative management play a role in pediatric patients?

“…However, reported outcomes in recent series are quite inconsistent, with improvements in renal function following diversion seen in 24%- 100% of patients. Such variability can perhaps be accounted for by the heterogeneity of studies particularly in terms of the cut-offs used to define poor function (DRF <20%, <15%, or <10%) (3)(4)(5)(6)16), and significant DRF improvement (DRF ≥10% at control (6,16); DRF increase ≥10% compared to the baseline (5); DRF ≥10% at control and PCN drainage greater than 200 ml per day (4); SRF and GFR more than 10% (3)), respectively. Unfortunately, all these parameters remain somewhat arbitrary.…”

“…Under these circumstances, management becomes more controversial. Some authors recommend direct nephrectomy, others direct pyeloplasty, and others a trial of temporary urinary diversion to begin with in order to assess the actual potential for function recovery before embarking on either nephrectomy or pyeloplasty (2)(3)(4)(5)(6)(7). The evidence, however, indicates that the likelihood of renal function recovery is generally limited in these situations and that no factor can reliably predict it (2).…”

Effectiveness of Full Length and Cut Percutaneus Nephrostomy in Pediatrics Population

“…In pediatric patients, PCN is used as a temporary drainage tube for urinary tract obstruction and as a bypass surgery prior to definitive corrective surgery [6]. Obstruction of the ureter-pelvic junction is the most common cause of significant dilatation of the renal collecting system in the fetus [7,8,9]. Kidney stone disease in children has become an epidemic in developing countries.…”