Postnatal management of bilateral Grade 3–4 ureteropelvic junction obstruction

Abstract

Introduction: Bilateral hydronephrosis on prenatal ultrasound can be managed expectantly or with surgical intervention. The treatment strategies and outcomes are not clearly defined. Methods: We conducted a retrospectively audit of outcomes of management of prenatally detected severe bilateral ureteropelvic junction obstruction (UPJO) in our institution.Patients with bilateral Grade 3–4 hydronephrosis were included. Those with complications like rupture, underwent bilateral intervention within 4 weeks; in the remaining, unilateral pyeloplasty was performed at 4–12 weeks. The contralateral renal unit was re-evaluated at a later date for further improvement or deterioration. All the patients were followed up with ultrasonography and renogram at 3 months, 6 months, and 1-year post operatively. The case records were analyzed for the resolution of antero-posterior diameter (APD) or the improvement in single-kidney glomerular filtration rate (s-GFR) in the operated units. Results: Over 15 years, 28 patients (56 renal units) had bilateral UPJO (male-to-female ratio = 13:1). Twelve units underwent neonatal intervention to tackle the complications (6 bilateral pyeloplasty), 17 units underwent early pyeloplasty, and 15 underwent late pyeloplasty. Twelve of the twenty-two (54%) contralateral units, which were stented/observed, resolved spontaneously. Receiver operating characteristics analysis revealed that those with initial APD <25 mm and initial s-GFR >35 ml/m were more likely to improve during the observation. Ten of the forty-four operated units (22%) failed to show an improvement. Units with initial s-GFR <10 ml/m had poor chance of postoperative functional recovery. Conclusions: In neonates with bilateral UPJO, the worse affected kidney is operated first, as it still has the potential to recover. The contralateral milder UPJO unit is known to recover spontaneously following unilateral pyeloplasty. In those with bilateral Grade 4 UPJO and mass, bilateral pyeloplasty is feasible. Alternatively, unilateral pyeloplasty + contralateral cystoscopic retrograde stenting may prevent rupture or functional deterioration in the opposite kidney.

Role of interventional radiology in the management of complex pediatric surgical cases

“…Bilateral ureteropelvic junction obstruction (UPJO) is a rare congenital anomaly, constituting <5% of all the UPJO cases [ 7 ]. Treatment of these cases is controversial.…”

“…Treatment of these cases is controversial. While some surgeons believe in concurrent pyeloplasty, others follow a successive approach of operating the poorer functioning side first [ 7 , 8 ]. In addition to the above two, few also believe in stenting the un-operated renal unit to prevent any further functional deterioration during the waiting time [ 7 ].…”

“…While some surgeons believe in concurrent pyeloplasty, others follow a successive approach of operating the poorer functioning side first [ 7 , 8 ]. In addition to the above two, few also believe in stenting the un-operated renal unit to prevent any further functional deterioration during the waiting time [ 7 ]. In complicated cases presenting as urosepsis or large mass causing respiratory distress, temporizing procedures such as percutaneous nephrostomy (PCN) and cystoscopy may be required for relieving the obstruction [ 7 , 9 ].…”

What's inside

“…The result of a retrospective study on 28 patients with severe bilateral hydronephrosis over 15 years has been presented. [ 6 ] Patients with complications such as rupture had bilateral intervention in 4 weeks and others had unilateral pyeloplasty between 4 and 12 weeks. In the unilateral intervention group, contralateral hydronephrosis resolved spontaneously on follow-up in 54% patients.…”

Editorial comment

“…The authors present one of the largest series on bilateral severe UPJ-O in neonates. [ 6 ] Among the 28 children, 8 (28%) had associated vesicoureteric reflux (VUR). The VUR resolved on conservative management except in one child who required reimplantation 1 year after pyeloplasty.…”