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

• 16 Mar 2020 11:37:38 AM
• |General Urology

15 years female child 

Comments(15)

• 

  Utsav Shah

  16 Mar 2020 12:08:23 PM

  Sir,

  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

  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

  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

  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?

  Thanks

• 

  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

  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

  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

  Thanks

• 

  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

  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

  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. 

  regards 

  Sunil

• 

  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,

  Venu

   

• 

  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

  17 Mar 2020 03:56:31 PM

  Would not hesitate to do pyeloplasty

  ---

• 

  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

  Amilal

• 

  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.