Ureteropelvic Junction Obstruction

in Children
Bustanul Arifin Nawas
Divisi Bedah Anak FK UNPAD

Hydronephrosis
Dilatation of renal collecting system result from
obstruction or reflux of urine
Interaction between glomerular hemodynamic and
alteration in tubular function
Discovered during maternal-fetal ultrasound
20-25% spontaneous resolution
Neonates with persistent hydronephrosis (44%),
caused by UPJ Obstruction

UPJ Obstruction
High Grade UPJ Obstruction
Result in hydrostatic distention, increased intrapelvic
pressure, & poor outflow urine
Chronic process irreversible kidney damage
Low Grade UPJ Obstruction

Developing kidney remain in homeostatic state

temporary growth and improvement

Etiology and Pathophysiology

Intrinsic Type

Etiology
Absence or reduction
of circular muscle fiber
Abnormality of
peptidergic innervation
Down regulation of
Cajal cell

Pathophysiology
Failure of transmission of
the peristaltic waves
across the UPJ
Failure of propulsion of the
urine ineffective
peristaltic wave
hydronephrosis

Etiology and Pathophysiology

Extrinsic Type

Etiology
Aberrant/crossing
renal vessel
Adhesive band
Arteriovenous
malformation
Ureteral fold

Pathophysiology
Compression, angulation,
or kinking of the UPJ

Clinical Presentation
Infant
Asymptomatic
Hydronephrosis discovered by prenatal US

Children

Abdominal flank mass

Episodic flank, cyclic abdominal pain
Gastrointestinal dyscomfort
Urinary tract infection
Nephrolithiasis
Hematuria
Anoreksia

Diagnostic Evaluation
1. Renal Ultrasonography
. to demonstrate dilatation
. information of the severity of hydronephrosis and
thickness of the renal cortex
. to indicate the level of obstruction
Grading of hydronephrosis (SFU)

0 : No splitting of renal pelvis

1 : Splitting of renal pelvis
2 : Splitting confined to sinus; calyces not dilated
3 : Renal pelvis dilated beyond sinus; calyces uniformly dilated
4 : Renal parenchyma thinned to < 50% the contralateral side

Diagnostic Evaluation.

Grading of hydronephrosis (SFU)

Diagnostic Evaluation.

2. Renal Scintigraphy :
to asses severely impaired renal function
to distinguish between obstructive and non-obstructive
dilatation
quantify differential renal function

Diagnostic Evaluation.

3. Voiding Cystourethrography

to investigate possible coexisting vesicoureteric reflux

(9-14%).

Diagnostic Evaluation.

4. Magnetic Resonance Urography

Gadolinum-enhanced magnetic
resonance urography (Gd-MRU)
distinguish between obstructive
and non obstructive collecting
system.

Management
Conservative management (watchful waiting) :
Direct physical examination
Ultrasound after birth (min 2 days)
Additional studies if UPJ obstruction is highly suspected.
Operative management :
Open surgery
(Flap techniques, Dismembered pyeloplasty)
Minimal invasive surgery
(Laparoscopic pyeloplasty, Robotic surgery, Endopyelotomy)

Management

Indications for conservative management:

Differential renal function >40%
AP diameter of the renal pelvis <30mm
Indications for surgery :
Symptomatic UPJ obstruction
Asymptomatic obstruction with reduced function
(<40%), AP diameter of the renal pelvis > 30mm
Failure of conservative management
No evidence of resolution in persisting asymptomatic
obstruction

Unilateral antenatal
hydropnephrosis
Postnatal
US
(2-5 days)

SFU grades
III and IV

SFU grades
I and II

US
4-8 weeks

Hydronephrosis
stable/resolved

Hydronephrosis
worsen

Repeat US vs
Observation

VUR

VCUG
3-6 months
Diuretic renal scintigraphy
vs
Gd-MRU

Manage VUR

(3-6 months for

1-2 years )

Workup and Management of

Antenatal Detected Hydronephrosis

Surgical criteria
met

Surgical criteria
not met

Surgery

Reassess 3-6
months

Management
Dismembered Pyeloplasty
(Anderson-Hynes)

Vertical Flap (Scardino-Prince)

Spiral Flap (Culp-DeWeerd)

Prognosis

By early detection and prompt surgery before renal

impairment occurs, the prognosis of UPJO is good.
Reconstructive surgery is always considered; renal
recoverability in young children is unpredictable.
Nephrectomy is reserved for only the most hopelessly
damaged and dysplastic specimens.

Thank You