Is it PUJO? Will you operate?

12 years female patient. 

Vague abdominal pain since couple of years. 
Investigated multiple time at many centers. 
Her GI endoscand CT scan were done before in January 2019.  CT report is attached. 
Since few days she has right flank vague pain. 
She was evaluated by urologists first time before couple of weeks. 
Attaching recent Diuretic scan done at Ahmedabad and USG report. 
She is advised for pyeloplasty. 
They are agree but want promise on relief from pain that she has since long. 
Please opine;
On diagnosis 
Pyeloplasty to do or not to do?

Is it PUJO? Will you operate?Is it PUJO? Will you operate?Is it PUJO? Will you operate?Is it PUJO? Will you operate?Is it PUJO? Will you operate?Is it PUJO? Will you operate?Is it PUJO? Will you operate?


  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    28 Jul 2020 09:09:05 PM

    Sir,if possible, kindly upload usg film too..

    Sir,I would like to offer her point in favour r..1.age..young age..long life span...can't take risk 
    2.. symptom...with procedure..her symptom will get relieved..
    In Renogram...
             Films r showing obstructive pattern on rt side..
             Numerical values showing obstruction with decrease renal function...
    Only thing that going against is.. graph..on f0's showing type3a type graph... abrupt fall after platue of graph...
    So I'm for pyloplasty..
    Thank u sir

  • Utsav Shah
    Utsav Shah
    29 Jul 2020 07:22:24 AM

    Respected Sir,

    Thanks for updating this case. I would like to mention a few points. 

    1) Patient is having unexplained right flank pain since. This patient is having a horseshoe kidney. So whether the pain is due to the PUJO or not needs to be ruled out completely because ideally the pain should be in pelvis or right iliac and lumbar region for her. 

    2)The renogram curve of right kidney appears to be 3A but it is probably due to a faulty study or a faulty ROC. Also, in F0 protocol which is used in children this can be a problem as the entire system is under stress from the beginning. If the study is repeated there is a chance that we can get a typical obstructed pattern. However based on the CT and patient’s presentation, a repeat DTPA might not be necessary. 

    3)She has a horseshoe kidney which in itself is prone to PUJO. Hence, she should be operated upon. 

  • shriram joshi
    shriram joshi
    29 Jul 2020 10:23:55 AM

    Dear anil,

    I think the horseshoe kidney is a red herring. What worries me is the shrinking kidney size, differential function of 20%, pelvis diameter 24 mm and no massive dilatation of calyces. With these findings the differential kidney function, renographic curve T1/2,cortical transit time cannot be relied on due to parenchymal dysfunction. In such situations I have looked carefully at cortical thickness of the kidney on USG. If it is between 5-7mm then pyeloplasty may help, but <5mm papery thin cortex pyeloplasty may not help. This kidney is an aftermath of long standing obstruction.
    Parents should be made aware success of pyeloplasty may be poor and there is no gaurantee that abdominal ache will subside. 

    Regardi other case no MCUG, no CT ivu.i would prefer to operate now rather than wait for deterioration of differential kidney function.

    CT ivu is over emphasized investigation.information on USG + TchEc renal scan gives all the information you need


  • Gyanendra Sharma
    Gyanendra Sharma
    29 Jul 2020 11:32:00 AM

    Dear Anil

    Decreasing size of kidney, decreased renal function & reducing parenchymal thickness would qualify for intervention
    However I would prefer doing a MCU bfeore intervention
    If MCU is normal then also I would do a RGP prior to pyeloplasty

    As regards the parents seeking assurance for relief from pain--counselling should help
    Another way could be to put a DJ & if that relieves her pain  then the  obstruction as the cause of pain would be established

  • shriram joshi
    shriram joshi
    29 Jul 2020 02:09:06 PM

    Why MCUG? Normal ureter on USG is unlikely to contribute to obstruction. Yes pre-op RGP would help.


  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Jul 2020 06:15:13 PM

    Thanks to all for your valuable inputs. 

    I have posted this case for RGP and if convinced pyeloplasty. 
    RGP: will do as advised by Dr. Gyanendra and S. S. Joshi Sir to understand anatomy in details before putting the incision as there are horseshoe kidneys...
    I will post details of RGP, approach and operative images tomorrow at the end of surgery...thanks 

  • Dr. Isteaq Shameem
    Dr. Isteaq Shameem
    29 Jul 2020 07:49:59 PM

    Isteaq Shameem

    Thanks to all. I would not prefer right away pyeloplasty. Preferably will put a          DJ stent after RGP and follow the symptom of pain. Since excretion is seen on both sides observing after DJ may be an option.Dysplastic component also may be present since the kidney is small and how much patient will benefit after pyeloplasty is a dilemma
    Looking forward to reading from Dr Anil findings

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Jul 2020 08:51:04 PM

    Thanks Dr. Shameem. 

    Somehow I didn't like option of stenting. In long term it doesn't serve the purpose.  My view. 
    I agree with dyspstic component and your comments related to that. 
    I will update post tomorrow. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    30 Jul 2020 05:07:47 PM

    Dear All, 

    I could dig up some images of Ct abdomen of 5his patient done in January 2019. 
    There are pre lasix and post laxis axial and coronal images.
    After that CT, urologist was not consulted until last month....thanks 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    31 Jul 2020 09:02:26 PM

    Dear All,

    Posting images;
    1. Right RGP 
    2. Adynemic/narrow segment, hugely dilated pelvis even after emptying it by small neak,  horseshoe kidney/fixed lower pole 
    3/4 Crossing major vessels, 
    PUJ/ upper ureter were bring in front of vessels.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Aug 2020 07:39:22 AM

    This operatibe image of major crossing vessels is missing

    Posting again

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    04 Aug 2020 11:00:07 AM


    Good job done.... Few queries...

    1. Why RGP...Any role in PUJO?
    2. How to judge "Adynamic segment"
    3. CECT KUB with Lasix ...Is it a new modality in investigation.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    04 Aug 2020 04:59:36 PM

    1.Why RGP in this case:

    Possibly Horseshoe kidneys Details of exact site, size of kidney and size of dilated pelvis and PUJo segments were  missing or not available.
    RGP: helped me understanding dilataion, size of pelvis and kidney rotation and its  medial placement. 
    I planed my incision accordingly very much anterirorly,  dissection started at lateral angle for shiefting peritoneim  medially to reach lower pole and pelvis retroperitonealy.
    Pelvis was hugely dilated and lower pole was fixed with opposite left kidney lower pole. 
    On emptying pelvis of very large volume of urine by putting neak I could identify ureter and crossing vessels. 
    2. How to judge adynaemic segment;
    I go write up to dilated ureter distal to narrow/adynaemic segment 
    3. CECT with lasix;
    Was advised in January 2019 to this female patient by gastroenterologist. 
    I strongly believe CT has no role in diagnosis of PUJO. It can just give more anatomical details listed by me in first paragraph. 
    But for that I do occasional RGP in cases like Horseshoe kidney, malrotated, Duplex or ectopic kidneys. And rarely MRU. 
    But big no to CECT(with lasix) for functional diagnosis in any cases of suspected PUJO. 

  • shriram joshi
    shriram joshi
    04 Aug 2020 06:29:01 PM

    Firstly heartiest congratulations to you and Nikesh for this achievement of 900 members.So long as you deliver good scientific material, in a short time you will reach 1000 members. 

    Older children like this case with PUJO more often present with vague upper abdominal ache with no localising signs. It is good USG will pick up PUJO. Common cause is a lower polar vessel or as in this case due to horshoe kidney a major branch.

    My  difficulty has been to distinguish between primary PUJO with external vascular compression, and just vascular compression without PUJO.
    Both require exploration. 

    So I have tended to do what you have done in this case viz. Pyeloplasty with anterior placement - anterior to the compressing vessels.

    Excellent documentation of imaging and operative pictures.
    I think  she will be relieved of pain but I am not sure of recovery of renal function. Long follow up will give the answer.

    Doing CT UROGRAPHY for a PUJO is an overkill and best be avoided.

  • Dr. Isteaq Shameem
    Dr. Isteaq Shameem
    05 Aug 2020 09:06:12 AM

    Isteaq Shameem

    Thanks Dr Anil for going ahead with exploration and doing what exactly needed to be done. Excellent documentation with the right idea of RGP. Yes, I fully agree with you regarding CT in PUJO, even IVU sometimes give clue regarding crossing vessel causing PUJO with an indentation at PUJ. Improvement of function remains a long term follow up but surely it will halt further deterioration.
    Thanks to Joshi sir and rest for their continuous contribution

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