we generally reserve surgical correction for babies with documented delayed drainage and diminished function (>10% difference on differential scan) on MAG3 lasix renogram. Progressive hydronephrosis on serial renal US with previously documented delay in drainage by renogram is also an indication for repair
In most cases, neonatal hydronephrosis is a relatively benign condition that can be followed safely by an initial non-operative approach unless there is evidence of obstructive injury. A follow-up protocol that permits early identification of a limited number of kidneys that may develop signs of obstruction and require pyeloplasty is crucial for a favorable outcome in patients with primary UPJ-type hydronephrosis. Onen's hydronephrosis grading system promises an easier and more appropriate follow up and timely treatment for children with this condition. A sufficient follow-up interval, especially during the first 3 years of life, is essential to help prevent permanent loss of renal function in kidneys that do develop signs of obstruction.
Neonatal Hydronephrosis should be strictly followed up by neonatal surgeon. Although simple dilatations seen commonly on USG scans do not equate with "Obstructions" its very important to detect PUJ obstructions early on. Dilatations less than 12mm could be conservatively managed without need to rush into additional scans. While dilatations more than 20 mm should be investigated without further delay.
Serial USG with renal planometry and corticomedullary thickness by an efficient radiologist well versed with these scans is sufficient. Serial rise in dilatations at cost of C:M differentiations warrent nuclear medicine scans (DTPA with lasix or MAG 3 scan) which will detect the obstructed system.
Obstructed systems should be operated in the first of half of second year or at first signs of obstruction whichever appears earlier. Renal Morphogenesis continues well upto the fourth year. However systems that are operated early on (usually in first two years) recover most nephrons unlike sytems operated later on (2 yrs - 4 yrs).
Progressive hydronephrosis on serial renal US with previously documented delay in drainage by renogram
and functions less than 40% and t half > 20 minutes.
A primary mechanical double PUIobstruction seems to be very seldom. I have seen 2 cases of bilatral PseudoPUI obstructions by spina bifida occulta ad children with 12 and 18 years where Anderson-Hynes didn't of course not help. If we have the posiibility we schould as soon as possible at these cases make a simple but efficient diagnosis of the lower urinary tract and like told above of the spinal corde.
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Indications for surgery in a neonatal PUJO (assuming diagnosis made by obstructive pattern on nuc. scintigraphy)
- symptoms : mass, uti
- us : tpd > 3 cm
- LLEC : split function < 40%
combination of all the above factors rather than looking at one in isolation will help to make a 'good' decision.
Trend :
- reduction in function > 10%
- increasing tpd
Special cases :
- Solitary kidney with pujo : tpd > 2cm warrants intervention
- B/L pujo : the side with lesser function or more dilatation to be operated first
ref :
Consensus Statement on Management of Antenatally Detected Hydronephrosis Indian Pediatrics 2001; 38: 1244-1251
Early surgery once its confirmed by RENAL SCANS the the PCS dilatation is due to an obstructive PUJ. I would surgery as early as six weeks if severe dilatations encountered. Pyeloplasty with an indwelling DJ stent - to be removed at six weeks. Surgery is straighforward - totally extra-peritoneal with minimal morbidity and upto 99% success rate.
Firstly we should respect to this comment that says :
It appears as if the first year is the most dynamic, either for better or worse of obstruction. These are not hard-and-fast rules and require adaptation to the
clinical context.
but generally this was recommended :
children with moderately severe to severe hydronephrosis, with caliectasis, will require ongoing monitoring and functional assessment.
For patients with less severe hydronephrosis, functional imaging is not usually useful and regular ultrasound imaging can provide useful data and can detect
worsening hydronephrosis that would warrant a functional assessment
.(Avner Pediatric nephrology 6th ed)
One needs to rule out a double obstruction at times eg VUJ obstruction with secondary PUJ - an MRU may be essential -
Indications to operate PUJ:
Development of symptoms (usually f-UTI if younger , pain if older)
Deteriorating renal function
Progressive, significant increase in HN
Parental choice???
.....................................................................
Who does best on observation protocol?
Asymptomatic
Those with high likelihood of spontaneous resolution (SFU grade I-III)
Renal scan done (SFU grade III) & renal function preserved
Antenataly hydronephrosis is today a case for intrauterine child-surgery. Nearly unbelievable but it exist unfortunately not everywhere around the corner Your Hainz
Dr Hanz: Surely only in a handful of very select cases and in highly specialized centres one would consider fetal surgery; not in every case!!
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