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Review of UPJReview of UPJ

ObstructionObstruction

November 7, 2007November 7, 2007

Chris Hoag, PGY5 UBC UrologyChris Hoag, PGY5 UBC Urology

ReferencesReferences

CWU9CWU9Ch115Ch115

AUAUS 2007AUAUS 2007Lessons 5 & 6Lessons 5 & 6

Literature reviewLiterature review

The Centre of the UniverseThe Centre of the Universe (video from Toronto Sick Kids Hospital)(video from Toronto Sick Kids Hospital)

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Cape Spear, NFLD(Easternmost point in Canada)

UPJO FactsUPJO Facts

1/1500 live births1/1500 live births

Clustering of presentation time:Clustering of presentation time:

Neonatal/antenatal (now the majority)Neonatal/antenatal (now the majority)

Adolescence/adulthood (symptoms)Adolescence/adulthood (symptoms)

#1 cause of antenatal hydro (48%)#1 cause of antenatal hydro (48%)

Boys > girls (>2:1)Boys > girls (>2:1)

L > R (2:1)L > R (2:1)

Bilateral in 10Bilateral in 10--40%40%

Runs in familiesRuns in families

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EtiologyEtiology

PrimaryPrimary

IntrinsicIntrinsic

ExtrinsicExtrinsic

SecondarySecondary

Primary UPJOPrimary UPJO

IntrinsicIntrinsic

AdynamicAdynamic segment/intrinsic narrowingsegment/intrinsic narrowing

Delayed/failedDelayed/failed recanalizationrecanalization after periodafter period

of obstructionof obstruction

Neuronal depletion in proximalNeuronal depletion in proximal ureterureter

Incomplete development of circular sm. m.Incomplete development of circular sm. m.

Alteration of collagenAlteration of collagen fiberfibercompositioncomposition

b/w sm. m. cellsb/w sm. m. cells

ValvularValvular((OstlingOstlingss) mucosal folds) mucosal folds

PersistentPersistent fetalfetal convolutionsconvolutions

UreteralUreteralpolypspolyps

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Primary UPJOPrimary UPJO

ExtrinsicExtrinsic

Crossing vessel (anterior)Crossing vessel (anterior)

RenalRenal malrotationmalrotation (over/under)(over/under)

PathophysiologyPathophysiology of Extrinsic UPJOof Extrinsic UPJO

Crossing vesselCrossing vessel two point of kinkingtwo point of kinking

WhereWhere ureterureterdrapes overdrapes over

Angulated at UPJAngulated at UPJ

Ensuing pelvic distension &Ensuing pelvic distension &

inflammationinflammation

Further adhesion kinking &Further adhesion kinking &22--point obstructionpoint obstruction

Ischemia, fibrosis,Ischemia, fibrosis, stenosisstenosis

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Secondary UPJOSecondary UPJO

Severe VUR (Grade IV/V) (10%)Severe VUR (Grade IV/V) (10%)

Kinking of tortuous system at relatively fixed UPJKinking of tortuous system at relatively fixed UPJ

Lower pole moiety of incomplete duplicationLower pole moiety of incomplete duplication


Severe VUR (Grade IV/V) (10%)Severe VUR (Grade IV/V) (10%)

Kinking of tortuous system at relatively fixed UPJKinking of tortuous system at relatively fixed UPJ

Lower pole moiety of incomplete duplicationLower pole moiety of incomplete duplication

StoneStone--related scarrelated scar

Iatrogenic (instrumentation)Iatrogenic (instrumentation)

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Associated Congenital AnomaliesAssociated Congenital Anomalies

GU Anomalies:GU Anomalies:

ContralateralContralateral UPJO = #1 (10UPJO = #1 (10--40%)40%)

VUR (up to 40%)VUR (up to 40%)usually low gradeusually low grade

Renal dysplasiaRenal dysplasia

MCDKMCDK

Renal agenesis (5%)Renal agenesis (5%)

Duplicated system (usually lower moiety UPJO)Duplicated system (usually lower moiety UPJO)

Horseshoe kidneyHorseshoe kidney Ectopic kidneyEctopic kidney

NonNon--GU Anomalies: VATERR (10GU Anomalies: VATERR (10--20%)20%)

Zion Canyon, Utah

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DiagnosisDiagnosis

PresentingPresenting S&SxS&Sx

InfantsInfants

HydronephrosisHydronephrosis on antenatal U/S = majorityon antenatal U/S = majority

Palpable abdominal massPalpable abdominal mass

FTTFTT

Feeding problemsFeeding problems

Sepsis (UTI) = presentingSepsis (UTI) = presenting SxSx 30% beyond30% beyond

neonatal periodneonatal period

Pain/Pain/hematuriahematuria (stones)(stones)

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Diagnostic DilemmasDiagnostic Dilemmas

Antenatal hydro doesnAntenatal hydro doesnt necessarily =t necessarily =

obstructionobstruction

Hydro from activeHydro from active diuresisdiuresis (e.g. late gestation fetal(e.g. late gestation fetal

kidneykidney high output, high compliance)high output, high compliance)

Temporary fetal kidney obstruction withTemporary fetal kidney obstruction with

spontaneous resolution (mucosalspontaneous resolution (mucosal

folds/convolutions)folds/convolutions)

Minimal hydro doesnMinimal hydro doesnt necessarily = no riskt necessarily = no risk IntrarenalIntrarenal vs.vs. extrarenalextrarenalpelvis with UPJOpelvis with UPJO

Olympic National Park, WA

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Pediatric UPJO W/UPediatric UPJO W/U

PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro

UltrasoundUltrasoundrenal & bladderrenal & bladder

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UltrasoundUltrasound

Delay postDelay post--natal U/S at least 48 hours (? 2natal U/S at least 48 hours (? 2

weeks)weeks) d/td/t relativerelative oliguriaoliguria in early postnatalin early postnatal

periodperiod

Neonate GFR doubles in first weekNeonate GFR doubles in first week

Risk of underestimating degree of hydroRisk of underestimating degree of hydro

Day 1 2 Weeks

UltrasoundUltrasound

Key factors to note:Key factors to note:

Degree ofDegree of hydronephrosishydronephrosis

Thickness of parenchymaThickness of parenchyma

EchotextureEchotexture of parenchymaof parenchyma

ContralateralContralateral hypertrophyhypertrophy

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SFU Grading SystemSFU Grading System

Grade 1 = renal pelvis splitting onlyGrade 1 = renal pelvis splitting only

Grade 2 =Grade 2 =pelvicalycealpelvicalyceal dilation (some calycesdilation (some calyces

only)only)

Grade 3 = significantGrade 3 = significantpelvicalycealpelvicalyceal dilation (alldilation (all

calyces)calyces)

Grade 4 = Grade 3 +Grade 4 = Grade 3 +parenchymalparenchymal thinningthinning


1

43

2

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103 infants

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UltrasoundUltrasound?Other Markers of?Other Markers of

ObstructionObstruction PelvicalicealPelvicaliceal diameter > 2.0cm = high risk ofdiameter > 2.0cm = high risk of

requiring surgeryrequiring surgery

RenalRenalparenchymalparenchymal ::pelvicalicealpelvicaliceal areaarea 1.6 = can be safely observed

Serial ultrasoundsSerial ultrasounds WorseningWorsening hydronephrosishydronephrosis = likely obstruction= likely obstruction

CompensatoryCompensatory contralateralcontralateral growthgrowth

Doppler U/SDoppler U/S RI > 0.75 = more likely obstructedRI > 0.75 = more likely obstructed

RI findings further provoked withRI findings further provoked with lasixlasix dosedose

Only useful in acute obstruction, not chronicOnly useful in acute obstruction, not chronic (AUAUS(AUAUS 0707--L5)L5)



Rule out VURRule out VUR

VCUGVCUG

Nuclear VCUGNuclear VCUG

Low grade VUR commonLow grade VUR common High grade VUR may cause secondary UPJOHigh grade VUR may cause secondary UPJO

If equivocal obstructionIf equivocal obstruction fix VUR & monitor UPJOfix VUR & monitor UPJO

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VCUGVCUG

NuclearNuclear RenographyRenography


Has supplanted IVP as primary functionalHas supplanted IVP as primary functionaldiagnostic testdiagnostic test

Considerable controversy in protocols forConsiderable controversy in protocols forperforming and interpretation b/w centresperforming and interpretation b/w centres

WellWell--temperedtempered renogramrenogram (SFU(SFU--PNMC)PNMC)

PrehydrationPrehydration with 10with 10--15 cc/kg NS15 cc/kg NS

Foley catheterFoley catheter DTPA or MAG3 (usually the latter now)DTPA or MAG3 (usually the latter now)

DiuresisDiuresis ((lasixlasix)) -- ???timing (F???timing (F--15, F0, F+20)15, F0, F+20)

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NuclearNuclear RenographyRenography InterpretationInterpretation

Obstruction:Obstruction:

Static measures (single test):Static measures (single test):

Rising drainage curveRising drainage curve

TT > 20min> 20min

DifferentialDifferential ffnn 20min)::

DehydrationDehydration

Suboptimal dose/timing of diureticSuboptimal dose/timing of diuretic

Poor renal function/immature kidneysPoor renal function/immature kidneys

Full bladder (no catheter)Full bladder (no catheter)

ROI poorly drawnROI poorly drawn

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VCUGVCUG


MRIMRI

MRIMRI

Not widely usedNot widely used thusfarthusfar

GadoliniumGadolinium--DTPA enhancedDTPA enhanced

Provide anatomical & functional informationProvide anatomical & functional information

Differential renalDifferential renal ffnn

Volume of enhancing renal parenchymaVolume of enhancing renal parenchyma

Renal transit time (akin to TRenal transit time (akin to T of nuclearof nuclear renogramrenogram))

Time from first cortical enhancement to contrast inTime from first cortical enhancement to contrast in ureterureteratat

or below lower pole of kidney afteror below lower pole of kidney after lasixlasix dose (>490sec =dose (>490sec =

obstrobstr.).)

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VCUGVCUG


MRIMRI

Whitaker TestWhitaker Test


NT & Foley catheterNT & Foley catheter

Pressure readings from renal pelvis & bladderPressure readings from renal pelvis & bladder

Flow rate @ 5Flow rate @ 5--10cc/sec10cc/sec

Obstruction =Obstruction = P > 20cmHP > 20cmH22OO

Unobstructed =Unobstructed = P < 12cmHP < 12cmH22OO

Criticisms:Criticisms:

CumbersomeCumbersome

No one knows how to do it anymoreNo one knows how to do it anymore

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VCUGVCUG


MRIMRI


BiomarkersBiomarkers

?Biomarkers?Biomarkers

NAG = NNAG = N--AceytlAceytl----DD--glucosaminidaseglucosaminidase

TGFTGF--11

Both found at increased levels in urine ofBoth found at increased levels in urine of

obstructed kidneysobstructed kidneys

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15 children underwent UPJO repair vs. 1115 children underwent UPJO repair vs. 11

controls with dilated noncontrols with dilated non--obstructed kidneysobstructed kidneys

TGFTGF

--

1 measured in renal pelvis, bladder of1 measured in renal pelvis, bladder of

UPJO kidsUPJO kidspreoppreop & 3& 3 mosmospostoppostop

Bladder TGFBladder TGF--1 measured in controls1 measured in controls


Obstruction = TGFObstruction = TGF--1 > 29pg/mg1 > 29pg/mg creatininecreatinine

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Who to treat?Who to treat?Special caseSpecial case

B/L UPJO (10% cases) & Solitary kidneyB/L UPJO (10% cases) & Solitary kidney

NuclearNuclear renogramrenogram & U/S interpretation more& U/S interpretation more

difficult as nodifficult as no normalnormal kidney for comparisonkidney for comparison

Treatment decision makingTreatment decision making

Relies on clinicianRelies on clinicianjudgementjudgementbased on:based on:

Drainage curvesDrainage curves

Degree ofDegree of hydronephrosishydronephrosis

Adult UPJO W/U SummaryAdult UPJO W/U Summary

Goals:Goals:

Confirm functionally significant obstructionConfirm functionally significant obstruction

Assessment of differential renal functionAssessment of differential renal function

Delineation of UPJ anatomyDelineation of UPJ anatomy

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Adult UPJO W/U SummaryAdult UPJO W/U Summary

NuclearNuclear renogramrenogram

Differential functionDifferential function

Drainage curvesDrainage curves

CTCT--angiogramangiogram

Vascular anatomy (?crossing vessel)Vascular anatomy (?crossing vessel)

Degree of hydroDegree of hydro

?Retrograde?Retrogradepyelogrampyelogram

Usually at time of definitiveUsually at time of definitive TxTx to assess strictureto assess stricturelengthlength

AdultsAdultsWho to Treat?Who to Treat?

SymptomaticSymptomatic

ComplicationsComplications

InfectionInfection

StonesStones

Renal function compromiseRenal function compromise

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Hot Springs, Tofino

ManagementManagement

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Management OptionsManagement Options

Open repairOpen repair

Minimally Invasive repairMinimally Invasive repair

EndoscopicEndoscopic

LaparoscopicLaparoscopic


Open surgical repairOpen surgical repair

techniques:techniques:

Foley YFoley Y--VVplastyplasty

No pelvic reductionNo pelvic reduction

CanCant transpose crossingt transpose crossing

vesselvessel

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Open surgical repair techniques:Open surgical repair techniques:

CulpCulp DeWeerdDeWeerdss spiral flapspiral flap

Can get significant length with large renal pelvisCan get significant length with large renal pelvis



DavisDavis intubatedintubated ureterostomyureterostomy

Stent & NTStent & NT

6 weeks for6 weeks for uretericureteric wall regenerationwall regeneration

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AndersonAnderson--Hynes dismemberedHynes dismemberedpyeloplastypyeloplasty

Allows transposition anterior to crossing vesselsAllows transposition anterior to crossing vessels

Excision of diseased segmentExcision of diseased segment

ReductionReductionpyeloplastypyeloplasty

Spiral flap can be used for extra lengthSpiral flap can be used for extra length


Open ApproachesOpen Approaches

AnteriorAnterior subcostalsubcostal musclemuscle--splittingsplitting

FlankFlankoff tip of 12 or supraoff tip of 12 or supra--1212

DorsalDorsal lumbotomylumbotomy

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Outcomes of Open RepairsOutcomes of Open Repairs

No review papers/metaNo review papers/meta--analysisanalysis

My review of dozens of papers:My review of dozens of papers:

Consistently >90% (92Consistently >90% (92--100%)100%)

SalvageSalvagepyeloplastypyeloplasty = 80%+= 80%+

Fog House, Saturna Island

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ManagmentManagment

Minimally invasive approachesMinimally invasive approaches

EndoscopicEndoscopic

LaparoscopicLaparoscopic

EndopyelotomyEndopyelotomy

Access:Access:

AntegradeAntegrade or retrogradeor retrograde

Technique:Technique:

Balloon dilatationBalloon dilatation

AcuciseAcucise

ColdCold--knifeknife

HotHot--knifeknife

LaserLaser

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EndopyelotomyEndopyelotomy

IndicationsIndications MildMild--moderate hydromoderate hydro

Good renal function (>30%)Good renal function (>30%)

ShortShort stenosisstenosis (100cc) Long stricture lengthLong stricture length

Poor renal function (

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RetrogradeRetrograde EndopyelotomyEndopyelotomy

4343 UPJUPJss in 42 pts.in 42 pts.

79% primary UPJ79% primary UPJ

30 Fr. Balloon diam.30 Fr. Balloon diam.

10 Fr. JJ x 6wks10 Fr. JJ x 6wks

ImprovementImprovement = >5% increase split= >5% increase split ffnn OROR

TT

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Outcomes:Outcomes:

MedianMedian f/uf/u 22mos (422mos (4--25)25)

LasixLasix renogramrenogram @ 3@ 3--66 mosmospostoppostop = 70% success= 70% success No obstruction = 6No obstruction = 6

Improved drainage = 1 (TImproved drainage = 1 (T 90min90min 28min)28min)

3 failed3 failedUrology 1995 46(1): 89-91


AcuciseAcucise

First publication 1994First publication 1994

2 kids2 kids

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AcuciseAcucise

77 patient series, 199177 patient series, 1991--19981998

No preoperative vascular imagingNo preoperative vascular imaging

PosterolateralPosterolateral incision of UPJ & JJincision of UPJ & JJ stentingstenting

78% success78% success 4% post4% post--operative hemorrhage (3 pts)operative hemorrhage (3 pts)

2 required2 required embolizationembolization

AcuciseAcucise EndopyelotomyEndopyelotomy

5252--81% radiographic success81% radiographic success

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LaserLaser ureteroscopicureteroscopic endopyelotomyendopyelotomy

2020 uretersureters in 18 adult patientsin 18 adult patients

11 stone11 stone--scar, 3scar, 3 ureteroentericureteroenteric ((neobladdersneobladders),),

5 UPJO, 1 primary5 UPJO, 1 primary uretericureteric

8 Fr8 Fr semirigidsemirigid ureteroscopeureteroscope, Holmium @ 10W, Holmium @ 10W(1J x 10Hz), incised to fat, 12F JJ stent x6wks(1J x 10Hz), incised to fat, 12F JJ stent x6wks


LaserLaser ureteroscopicureteroscopic endopyelotomyendopyelotomy

F/U = nuclearF/U = nuclear renogramrenogram or U/S & IVPor U/S & IVP

Mean stricture length = 2.25cmMean stricture length = 2.25cm

MeanMean f/uf/u = 60= 60 mosmos (46(46--74)74)

80% success80% successbothboth uretericureteric & UPJ& UPJ

1 UPJO failure = high insertion1 UPJO failure = high insertion

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LaserLaser EndopyelotomyEndopyelotomy vs.vs. AcuciseAcucise

RCT, 2001RCT, 2001--20032003

40 adult patients (mean age 39); 20/group40 adult patients (mean age 39); 20/group

14 primary UPJO; 26 secondary14 primary UPJO; 26 secondary

PreopPreop w/uw/u = IVP, CT for vasculature,= IVP, CT for vasculature, lasixlasix renogramrenogram

J Urol 2006, 175: 614-618



Techniques:Techniques:

14/714/7 endopyelotomyendopyelotomy stent vs. 7 Fr JJstent vs. 7 Fr JJJ Urol 2006, 175: 614-618

-0.5 cc contrast in balloon to ensure

position

- 75-100W x 5 sec as 2cc injected in

balloon

- re-fire x1 if still waisted

- Keep inflated x10min for hemostasis

- Retrograde pyelogram to confirm

extravasation

- 1.2 J, 10Hz = 12 W

- Lateral incision to fat

- 8 Fr. Semirigid ureteroscope

- Balloon diln prn for hemostasis (1 pt)

AcuciseAcuciseLaserLaser EndopyelotomyEndopyelotomy

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SuccessSuccess = subjective improvement in= subjective improvement in SxSx

with objective improvement in obstructionwith objective improvement in obstruction

(T(T

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J Urol 2006, 175: 614-618



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Tofino Sunset

AntegradeAntegrade EndopyelotomyEndopyelotomy

Adults & older children/adolescentsAdults & older children/adolescents

ViaVia nephrostomynephrostomy tract (posterior middle calyx)tract (posterior middle calyx)

Dilation, coldDilation, cold--knife,knife, electrocauteryelectrocautery, or laser, or laser

EndopyelotomyEndopyelotomy stent x6wksstent x6wks

Advantages:Advantages:

Concomitant PCNLConcomitant PCNL Anatomic factors thatAnatomic factors that

precludepreclude ureteroscopyureteroscopy

Direct visionDirect vision

Disadvantages:Disadvantages:

Multiple anestheticsMultiple anesthetics Increased morbidityIncreased morbidity

Longer hospital stayLonger hospital stay

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19901990--20022002

37 children with primary UPJO37 children with primary UPJO

Mean age 11.5 yrs (4.5Mean age 11.5 yrs (4.5--17)17)

PreopPreop DxDx = U/S & IVP (no= U/S & IVP (no renogramsrenograms)) AllAllpercutaneouspercutaneous antegradeantegrade endopyelotomyendopyelotomy

F/U = IVP at 1 yearF/U = IVP at 1 yearpostoppostop


Technique:Technique:

UreteralUreteral cathetercatheter methylenemethyleneblue in pelvisblue in pelvis

MiddleMiddle calycealcalycealpuncturepuncture

Dilated to 26 Fr.Dilated to 26 Fr.

Wire placedWire placed antegradeantegrade across UPJ (catheter removed)across UPJ (catheter removed)

ColdCold endopyelotomyendopyelotomy knifeknifedorsolateraldorsolateral incision to fatincision to fat

66--12 Fr. JJ stent or12 Fr. JJ stent or transtrans--renal drainrenal drain x 6 weeksx 6 weeks

AntegradeAntegrade nephrostogramnephrostogram extravasationextravasation confirmed fullconfirmed full--

thickness incisionthickness incision

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Outcomes:Outcomes:

Complications:Complications:

2 children required exploration2 children required exploration d/td/tbleeding frombleeding from

crossing vesselcrossing vessel ligation & openligation & openpyeloplastypyeloplasty

4 children with fever4 children with fever ampicillinampicillin && acetominophenacetominophen

Hospital stay = 2Hospital stay = 2--10 days (mean = 6)10 days (mean = 6) 81%81% goodgood, 8%, 8% satisfactorysatisfactory, 11% failures, 11% failures



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So long ago, I cant remember

LaparoscopicLaparoscopic PyeloplastyPyeloplasty

First described in adults in 1993 (First described in adults in 1993 (KavoussiKavoussi))

First described in kids in 1999 (Tan)First described in kids in 1999 (Tan)

First pediatric robotFirst pediatric robot--assisted described in 2002assisted described in 2002(Peters)(Peters)

TransperitonealTransperitoneal vs. retroperitonealvs. retroperitoneal

Probably little advantage in child < 2yrs (DLProbably little advantage in child < 2yrs (DLequally nonequally non--morbid)morbid)

Increasingly the preferred firstIncreasingly the preferred first--linelineapproachapproach

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Head Feet

R side down


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Expanding indications:Expanding indications:


Renal calculi (concomitantRenal calculi (concomitantpyelolithotomypyelolithotomy))

Solitary kidneysSolitary kidneys

Anatomically anomalous kidneysAnatomically anomalous kidneys


15 pure15 pure retroperitoneoscopicretroperitoneoscopicpyeloplastiespyeloplasties vs.vs.

first 8first 8 DaVinciDaVinci--assistedassistedpyeloplastiespyeloplasties

Robot used forRobot used for anastamosisanastamosis onlyonly

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Operative (skinOperative (skin--skin) time significantly shorter forskin) time significantly shorter for

robot (172 vs. 210 min)robot (172 vs. 210 min)

Setup time for robot = 40 minSetup time for robot = 40 min

Conclusion: for first 8 cases, robot was time neutral,Conclusion: for first 8 cases, robot was time neutral,complication neutral, hospitalcomplication neutral, hospital--stay neutralstay neutral


RoboticRobotic--assisted Success Rates: 94assisted Success Rates: 94--100%100%

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Treatment Algorithm (Adult)Treatment Algorithm (Adult)

Outcomes SummaryOutcomes Summary

52-81%2Limited useAcuciseAcucise

88-100%87-100%LaparoscopicLaparoscopic

PyeloplastyPyeloplasty

67-88%72-92%3AntegradeAntegrade

endopyelotomyendopyelotomy

73-85%2~67%LaserLaser

endopyelotomyendopyelotomy

86-100%90-100%Open repairOpen repair

Adult success ratesAdult success ratesPediatric success ratesPediatric success ratesTechniqueTechnique

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Outcomes SummaryOutcomes Summary

References:References:

1.1. Tan et al, Urology 1995, 46(1): 89Tan et al, Urology 1995, 46(1): 89--9191

2.2. ElEl--NahasNahas, JU 2006, 175: 614, JU 2006, 175: 614--618618

3.3. TallaiTallai, J, J EndourolEndourol 2004, 18(10): 9522004, 18(10): 952--88

Primary Treatment FailurePrimary Treatment Failure

Salvage = try the other optionSalvage = try the other option

72 adult patients72 adult patients AntegradeAntegrade endopyelotomyendopyelotomy

MeanMean f/uf/u = 88.5= 88.5 mosmos

87.5% clinical & radiographic success87.5% clinical & radiographic success

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Primary Treatment FailurePrimary Treatment Failure

Salvage = try the other optionSalvage = try the other option

43 adult patients underwent open43 adult patients underwent openpyeloplastypyeloplasty

afterafter endopyelotomyendopyelotomy failurefailure 95% clinical & radiographic success95% clinical & radiographic success

PostPost--treatment Followtreatment Follow--upup

Pediatric UPJO:Pediatric UPJO:

Serial U/SSerial U/S

Gradual improvement in hydro is the ruleGradual improvement in hydro is the rule

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HistologicHistologic Findings in UPJOFindings in UPJO

Biopsy findings of kidneys with UPJOBiopsy findings of kidneys with UPJO

Dilation of collecting ducts & BowmanDilation of collecting ducts & Bowmans spaces space

Decreased #Decreased # glomeruliglomeruli

Interstitial fibrosis & inflammationInterstitial fibrosis & inflammation

Global/segmental sclerosisGlobal/segmental sclerosis

Cortical cystsCortical cysts

Duck Sanctuary

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SummarySummary

SummarySummary

DiagnosisDiagnosis

Kids:Kids:

U/SU/S

VCUGVCUG

RenogramRenogram

Adults:Adults:

CTACTA RenogramRenogram

?retrograde?retrograde

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SummarySummary

Decision to treat:Decision to treat:

SymptomsSymptoms

Complications (stones, infection)Complications (stones, infection)

Declining renal functionDeclining renal function

U/S criteria =U/S criteria =parenchymalparenchymal thinning,thinning, contralateralcontralateral

hypertrophyhypertrophy

RenogramRenogram criteria = worsening splitcriteria = worsening split ffnn, ?drainage, ?drainage

curves, ?Tcurves, ?T

SummarySummary

Treatment modality:Treatment modality:

Kids:Kids:

Open > EndoscopicOpen > Endoscopic

Lap data emerging (esp. age 2+)Lap data emerging (esp. age 2+)

AdultsAdults

Lap = OpenLap = Open >> EndoscopicEndoscopic

First line choice = discretion of clinicianFirst line choice = discretion of clinician

SalvageSalvage

PyeloplastyPyeloplasty EndoscopicEndoscopic

EndoscopicEndoscopic PyeloplastyPyeloplasty

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THE END

nov-7-07

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