Sonography measures TPD, parenchymal thickness. Do any other parameters such as real resistive index have a role? Nuclear scan usually looks at curve pattern and split function. Can transit time be used? Can histology help with fibrosis/smooth muscle orientation?
Hello,
we manage PUJ like most of the centers essentially with the help of MAG3 Nuclear scan and lasix, studying function and T 1/2 voidance.
it seems indeed that transit time is an early sign of impairment (look to a paper from our departement)
Urology. 2013 Sep;82(3):691-6. doi: 10.1016/j.urology.2013.03.041. Epub 2013 May 29.
Predicting the clinical outcome of antenatally detected unilateral pelviureteric junction stenosis.
Duong HP1, Piepsz A, Collier F, Khelif K, Christophe C, Cassart M, Janssen F, Hall M, Ismaili K.
Dear Dr Steyaert
We do LLEC scan instead of MAG 3. Transit time is said to be possible on a prospective basis rather than from retrospective recorded data. Would like to know your experience on the same.
Also, can I ask for the full text of the article ?
Thanks
When the patient has colics after feeding, you only need to know if the kidney has more than 10% function to proceed to surgery. When the anteroposterior diameter is 50 mm's or more, the same is true. When the kidney is palpable as a solid tumour, surgery will be needed as well. When the patient has hypertension, there is a reason to do surgery. In other cases, we take split renal function of less than 40% as an indication for surgery without looking at the curves or T1/2. Adequate hydration is needed for the MAG3 scan, the max of the normal kidney should be reached after approximately 3 minutes. Resistive index has proven to be a false parameter as has parenchymal transit time. When in doubt, we often use ultrasound after hydration and furosemide as an extra help. Measure the AP diameter, give the patient extra fluid and furosemide and do a new ultrasound one hour later. If the diameter is the same and the patient is not uncomfortable surgey is probably not needed.
Thanks Prof DeJong for the comment. But, as per literature, TPD >30 mm with < 40% is supposedly the criteria for surgery. Do you wait until the TPD crosses 50mm ?
You have also said you do not look at the curve pattern, which is again used commonly to comment on the diagnosis / need for surgery. Especially in the post op setting, the change in the curve pattern / improvement in drainage is supposed to denote the surgical success. What parameters/ investigations do you take to say the postpyeloplasty success rate? Also would like to know your opinion on histology.
Thanks
I do not totally agree on that. The most difficult cases are those with a relatively small intrarenal pelvis and massive dilatation of calyces. They can have a TPD of 15 mm and still need surgery urgently because of function under 40% or deteriorating function. And indeed, postoperatively we do look at the curves to see if drainage occurs. We use mainly ultrasound to look at postop success but sometimes this remains difficult in a preop massively dilated kidney. When in ultimate doubt postoperatively, occasionally we will do an antegrade pressure recording measuring the pressure in renal pelvis and bladder. (approximately 1 in 45 operated patients). When pressure gradient is under 20 cm's at 10 ml/minute filling situation is safe. When pressures are higher we dilate the puncture site and put in a 12 Fr resectoscope to open a scarred junction (and leave a JJ stent postop for a few weeks). This has been published in recent years. Look in pubmed for Jong tp and you will find the artcles. I have no special ideas on histology.
I use the US ,renal scan renal scan helps and symptoms to make the indication for surgery. I do the pyeloplasty laparoscopically in all cases. In small children it is better to place the stent in a retrograde fashion, so I also do a retrograde at that time which helps define the length of the narrow segment of the ureter and how aggressively to spatulate.
Pediatric Laparoscopic Pyeloplasty: Lessons learned from the first 52 cases. Chacko LA, Piagio LA, Neheman A, González R. Journal of Endourology. 2009; 23(8) 1307-11
Dear Dr Gonzalez
When do you take up these children for evaluation post operatively with US & Nuc scan ?
Postoperative diuresis renography and ultrasound in patients undergoing pyeloplasty: Predictors of surgical outcome. Neste MG, duCret RP, Finlay DE, Sane S, González R, Boudreau RJ, Kuni CC. Clinical Nuc Med 1993; 18: 872-876
Dear Dr Gonzalez
There is a practice that nuclear scan is to be undertaken after about 6months, as it is claimed that resolution of the pelvis dilatation takes longer. Wonder what is your view on this ?
Can I request full text of the article on post op diuresis renography pls ?
Regards
The most important indicator for the requirement of surgery is progressive increment in the dilatation of the hydronephrosis in serial ultrasounds
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