Antenatal right HN- Postnasal investigations- How early surgery?

2 months healthy boy with history of antenatal HN presented with following investigations-;

USG- 3days and  1 month
Diuretic renal scan done at 2 months 
Please discuss diagnosis?
Will you suggest anymore investigations to support your diagnosis?
If surgery- how early?

Antenatal right HN- Postnasal investigations- How early surgery?


  • Dr. Anil Takvani
    Dr. Anil Takvani
    13 Jun 2020 01:51:36 PM

    Uploading renal scan 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    14 Jun 2020 04:56:25 PM

    I am putting case details again. 

    Antenatal detection of severe right HN in third trimester. 
    Now two months,  healthy. 
    Mother feels lump in right flank at times. 
    Three uses done. Images of two available.  One  month and recent one. Attaching both.  Renal scan done at 2 months,  already posted. 
    Please  discuss the further management. 
    Pyeloplasty? How early?
    Your preferred approach in 2 months child.  Weight of child is 5.7kg.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    14 Jun 2020 04:58:12 PM

    Attaching report of last USG 

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    14 Jun 2020 05:12:35 PM

    Supranormal function in Rt kidney with obstructive curve.
    In this situation pyeloplasty may not show any improvement both in wash out curve and in SRF... So wait and watch with USG renometry. Renogram to be done as dictated by the Renometric parameters... Parents need to be counselled, that Pyeloplasty would be necessary on deterioration of SRF > 5% .

  • Dr. Anil Takvani
    Dr. Anil Takvani
    14 Jun 2020 05:25:50 PM


    Kidney is palpably enlarged 
    Pelvic dilatation is almost 40 mm. Cortex is thinned out. 
    CTT is very much delayed.
    Why not to operate? I think any delay can be responsible for increase in nephron damage...

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    14 Jun 2020 06:55:19 PM

    If you think, the preop parameters (particulaly CTT) would be reversed; then you may do Pyeloplasty. 

    But I would like to wait for deterioration of SRF after counselling the parent. 

  • shriram joshi
    shriram joshi
    17 Jun 2020 10:17:57 AM

    I would advise parents for a pyeloplasty after getting ok from paediatrician, anaestheologist. The reasons are :

    A history from mother of intermittent palpable rt kidney. This occurs when there is brisk diuresis after breast feeding or any other fluid. With PUJO
    pelvis balloons up and kidney becomes palpable, but settles down after sometime when pelvis empties.

    B USG shows AP diameter of 38 mm +
    Significant dilatation of calyces + thinning of parenchyma to 4.5 mm + no ureter is seen. Pelvis shows no debris within suggesting no infection
    With these findings if you do pyeloplasty soon there is 90% chance of full recovery.
    It would have been nicer if AP diameter of pelvis in supine & prone position. Just another clue regarding severity of PUJO

     C. Renogram shows delayed cortical transit time (CTT) + an ascending curve not touching base line + retention of dye in delayed film + Supra normal differential function of 52% (>50%} , all suggesting PUJO
    mind you renogram is a total body radiation for a child. One can follow the child on USG and assess progression if any instead of repeat renogram

    For above reasons I would recommend pyeloplasty.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    24 Jun 2020 07:31:21 PM

    I am posting operative images of hydropelvis and HN kidney with long adynaemic PUJ.

    These images proves there was no point in waiting anymore in this case. 
    How much he will show improvement in USG parameters depends on how proper dependent pyeloplasty done and function of nephrons.  Will post follow up USG images and if possible follow up diuretic scan to see how much CTT improved?
    Post is open for many relevant discussions on operative indications and post operative outcomes and ofcourse technique of pyeloplasty in infants. 

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