15 years female -Recurrent right flank pain -right hn PUJO like

15 years female child 

Right flank pain off and on since last couple of months. 
No UTI. 
S.  Creatinine normal. 
USG : Right HN,  dilated pelvis,  AP diameter 30 mm. Calyceal dilation present. Cortical thickness 10mm. 
Ureter normal,  bladder normal,  opposite renal unit normal. 
She came with investigations attached in this post. 
What is your diagnosis? 
Is she over investigated? If yes which investigation is done unnecessaryley in this case? 
How you would have investigated? 
Will you operate?  Operation of your choice? 

15 years female -Recurrent right flank pain -right hn PUJO like 15 years female -Recurrent right flank pain -right hn PUJO like 15 years female -Recurrent right flank pain -right hn PUJO like 15 years female -Recurrent right flank pain -right hn PUJO like 15 years female -Recurrent right flank pain -right hn PUJO like 15 years female -Recurrent right flank pain -right hn PUJO like


  • Utsav Shah
    Utsav Shah
    16 Mar 2020 12:08:23 PM


    Kindly correct if I'm wrong.
    Based on what I have seen and read, this patient seems to have apt investigations. Maybe a CT could have been avoided and a DTPA done directly based on Ultrasound report.
    Patient needs Right Dismembered pyeloplasty

  • Parthraj Jadeja
    Parthraj Jadeja
    16 Mar 2020 12:19:39 PM

    As has been the classic teaching one functional( DTPA) and one anatomical study(CTU or RGP ) is required for complete evaluation of PUJO before going for correction. So I think this is a properly evaluated patient.

  • Parthraj Jadeja
    Parthraj Jadeja
    16 Mar 2020 12:21:35 PM

    In case of reliable USG images we can avoid CTU and only RGP at the time of surgery is acceptable.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    16 Mar 2020 12:32:34 PM

    Patients in this age groups with dull pain of off and on nature with PUJO like USGs are having high chances of having crossing renal vessels responsible for intermittent short of obstruction to PUJ.

    Dose that changes investigation algorithm? Is CT mandatory in these cases? Or RGP or limited plate IVP can provide sufficient information on possibilities of CRV?

  • Utsav Shah
    Utsav Shah
    16 Mar 2020 01:02:08 PM

    Yes Anil sir, This patient is evaluated aptly. 

    RGP is not and cannot be a substitute to CT Urogram as perinephric events can only be seen on a CT and not on RGP. 
    Doing an RGP before a Pyeloplasty as a routine is a matter of controversy. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    16 Mar 2020 01:05:39 PM

    Do you think fMRU can be a better investigation if available in compare to CT IVU? Why? and Why not?

  • Dr. Isteaq Shameem
    Dr. Isteaq Shameem
    16 Mar 2020 01:36:11 PM

    Dr Isteaq Shameem 

    This is a case of PUJ obstruction due to crossing vessel as indentation seen on CT urogram. After USG, I would prefer IVU & DTPA rather CT urogram,radiation dose and cost of CT Urogram should also play role in suggesting investigations

  • aditya parikh
    aditya parikh
    16 Mar 2020 02:54:43 PM

    I think the patient is appropriately evaluated and as mentioned above needs a dismembered pyeloplasty.

  • Utsav Shah
    Utsav Shah
    16 Mar 2020 04:01:01 PM

    Yes Anil sir. MRU can be done. 

    But most paediatric urologists prefer an MRU only when there’s an altered renal function. CT is always preferred. 

    Advantages of MRU:
    1. Can be done in altered RFT
    2. Excellent signal contrast resolution of soft tissues
    3. Dynamic MRI is a good test which can combine anatomical and functional study and includes studying the static and excretory phases 

    Disadvantages of MRU:
    1. Needs GA in children. Sometimes catheterisation is also needed in Dynamic MRI. 
    2. Associated Stones can be missed(as they are seen as filling defects)
    3. Urologists are trained and comfortable with reading a CT more than an MRI. Cost is also a limitation. 

  • Sunil Moteria
    Sunil Moteria
    16 Mar 2020 06:47:55 PM

    adequately investigated pt, as Parthraj and Utsav rightly said the Anatomical n Functional demostrated. Regarding the identification of CRV - how does it going to matter the management . This Girl needs a definative Pyeloplasty. 


  • Venugopal P
    Venugopal P
    17 Mar 2020 10:58:04 AM

    Dear All,

    I find that most of you are for definitive Pyeloplasty.

    I would like to pose a few questions for which I am hopeful that answers will be provided.

    Do all Crossing Lower polar vessel with Hydronephrosis mandate Pyeloplasty? Reasons for and against

    If against, what are the other methods to treat such a situation? On what considerations you decide against Pyeloplasty?

    Apart from the notching in the Ureter at the level of vessel crossing, are there other methods to suspect Vessel crossing preoperatively?

    With warm regards,



  • Utsav Shah
    Utsav Shah
    17 Mar 2020 12:36:20 PM

    Respected Venugopal Sir,

    I have read about one Hailstorm procedure(not sure abt the spelling) where the lower pole vessel is hitched up to release the compression caused by it. 

    Lower pole vessel is an associated finding. The actual reason for 
    obstruction is the aperistaltic segment which needs treatment sir. Pyeloplasty is decided when the system is obstructed with Type 2,Type 3b and Type 4 O’ Reilly curves on Diuretic Renogram. Otherwise in Type 3a curve the patient can be observed. 

    With Regards to Other methods for lower pole vessel preop: CT angio can be asked for along with the CT urogram. 

    Kindly correct me if wrong sir. 

  • JG Lalmalani
    JG Lalmalani
    17 Mar 2020 03:56:31 PM

    Would not hesitate to do pyeloplasty

  • Amilal Bhat
    Amilal Bhat
    18 Mar 2020 09:34:57 AM

    Vessel alone is unlikely cause of obstruction.associted aperistaltic segment is responsible so pyeloplasty is better choice


  • Ravindra Sabnis
    Ravindra Sabnis
    20 Mar 2020 04:47:23 PM

    I also agree with Dr AMilala Bhatt. Just a crossing vessel may not be sole cause of PUJ obst. Also having taken up for pyeloplasty - it is always risky just to do Hellstorm procedure. 

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