What would be the practice in a 4 weeks child with antenatally detected unilateral HDN with PUJO when the SRF is only 5%? Pyeloplasty, PCN followed by Pyeloplasty or nephrectomy?
Most of the poorly functioning UPJO kidneys show improvement in function and not all such kidneys should be removed without a trial of PCN.
[Gupta DK, Chandrasekharam VV, Srinivas M, Bajpai M. Percutaneous nephrostomy
in children with ureteropelvic junction obstruction and poor renal function.
Urology. 2001 Mar;57(3):547-50.]
We do pyeloplasty by a dorsal lumbar approach. Get a Scan done after 6 months. A regular follow is done monthly. If the function improves we retain the kidney or do lap nephrectomy.
Thank you for your inputs Dr Kothari.. I would like to know your experience in cases like this where the baseline DRF was 5% and what was the max level of increase in function that was achieved? May be in approx. figures.......and how many of these kidneys could escape nephrectomy? and in a working environment where the entire expense is borne by patients [may not be always be the case, as in public hospital setup where patient may not spend even a penny] can this approach of repeated GA and Major surgical endeavors with its incurring cost be justified? Why not put a nephrostomy which can even be done as a office procedure with USG guidance and decide on it later? This has been our procedure in older children presenting late. However this child is only 2 months but does this age make any difference on the approach? this is the crux of the matter.
Regret for the delayed reply. PCN is a 'safe' way out and also can objectively determine the salvageability. But the counterpoint is at the time of reop, messy adhesions make things very difficult. Another point is when a kidney is poorly functioning (
I would place a double J stent and repeat the scan in 1 month, then proceed with nephrectomy or pyeloplasty
Can't expect much from a 5% kidney. Will be asymptomatic, so why not wait and watch.
Most of the time SRF5% the kidney has a good chance that it wont work well. However, uf you had done a EC scan or DTPA scan the function may improve slightly with decompression either by a nephrostomy or by Retrograde DJ stenting followed by a DMSA in few months would give u the best SRF and then u can decide on pyeloplasty or nephrectomy or observation.
Clearly warn parents about no recovery of SRF and further loss prior to taking this case up for any intervention
Will do DMSA baseline for more accurate DRF and then Pyeloplasty ... we have cases that preoperative function was
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