Persistent hydronephrosis/hydroureteronephrosis following primary valve treatment is a known sequelae following PUV treatment. This could be due to dilated/tortuous ureters, persistent VUR/VUJ obstruction (though rare), dysplastic ureters. A secondary pelviureteric junction obstruction may also be a possibility-wherein the ureteral dilatation may resolve but the PUJ obstruction may not resolve (considering PUJn is a potential site for narrowing/kinking). After ruling out distal obstruction, how many would tackle the PUJO by doing a pyeloplasty. How can we confirm the presence of PUJ Obstruction and how early should we operate.Please elaborate on evaluation in such children, especially with normal renal parameters and antenatally diagnosed PUV. Regards.
If you mean 2ry PUJO due to infection, this is rare. 2ry PUJO usually means obstruction after PUJ surgery. To prove infravesical obstruction usually pressure-flow study is used, although there are no reference cutoff points for children. Some times PUV lead to valve-bladder syndrome with poorly functioning bladder leading to upper tract obstruction or reflux. If diuretic renogram was done it may show obstruction but can't differentiate the site of obstruction. Whatacker test can show the difference between renal pelvic and bladder pressure.If significant obstruction at the level of the PUJ was proved it should be corrected. We have to clear infection, keep on suppressive therapy, monitor renal function by renography and correct anatomical defect if renal deterioration or frequent febrile UTI were detected.
To differentiate between PUJO from ureteral obstruction in diuretic renogram you can widen the region of interest to detect tracer in upper ureter which may exclude PUJO
Secondary PUJO is rare but if suspected (after R/O distal obstruction and poor bladder dynamics) then it can be confirmed with renal dynamic scan as mentioned by Ahmed.
A short period of double J stenting (6 weeks may be..) on the suspected side can also help in checking resolution of symptoms and other indicators (for example APD of pelvis) that had prompted suspicion of PUJO at the first place. If on the affirmative ...Pyeloplasty follows.
Dear Anjan, placing a stent would be able to prove obstruction but is there a risk of infection(esp. post BOO). As we are seeing more and more cases of antenatally diagnosed PUV, we may have to find a way to asses and tackle secondary PUJO in persistent upper tract dilatation. Can intravenous urogram confirm presence of PUJ with normal lower tract. I am concerned about the timing of pyeloplasty if at all required especially at the time when kidney is maturing,to optimise our treatment.
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