Prenatally Detected PUJ Obstruction

• 10 Apr 2021 02:35:16 PM
• |Pediatic Urology

Respected Seniors and Friends

Comments(5)

• 

  Dr. Anil Takvani

  11 Apr 2021 10:31:20 AM

  Thanks for sharing case with required investigations. 

  I would prefer to operate,  my points in favor of this decision are:

  Moderate HN with dilatation of pelvis and all the calyces.  Though AP diameter of renal pelvis in transverse plane at renal sinus is not mentioned but it is significant. 

  
  

  Thinking of parenchyama 

  
  

  Left split function less than 40%

  
  

  CTT is non uniform and increased, >3 minutes

  
  

  Most of the radioisotope is retained in pc system even in delayed frames 

  
  

  Forget about diuretic drainage curve...

  
  

  Do a very good pyeloplasty 

  
  

  Thanks 

• 

  Gyanendra Sharma

  11 Apr 2021 11:00:46 AM

  I would agree with Dr. Anil that the system looks dilated and calyces ar dilated

  I personally  felt that the Cortical transit time was 3minutes

  Hence a sonography was done at my center which showed marked decrease in AP diameter in prone position--the images  and findings are attached

  The patient was advised regular follow up and the findings of serial USG are also attached 

  His last USG done was done 6 months after the Renogram and it shows an APD of 10mm  with a good cortical thickness of 6-7 mm.

  This brings forth two important questions

  1. Should we take Differential function of < 40% as an absolute criteria for surgery

  2. How can sonography and cortical transit time be used  to determine  the need for surgery--in this aspect I am attaching the algorithm we had proposed  and the paper was published in 2017 in gold journal of urology

  
  

  I personally feel that USG can be used more easily to decrease the need for repeating renograms

  In this case a repeat Renogram would definitely be indicated as the initial Differential function was 35% but at present getting it done in my part of the country is very very difficult-- this patient will have to travel > 350 km to get the renogram done

  
  

  Opinion of all who are managing such patients would be hugely appreciated as it would ignite a debate  which would help formulating guidelines in management of these patients

  
  

  View Document

• 

  Gyanendra Sharma

  11 Apr 2021 11:03:31 AM

  The follow USG details are enclosed in the document attached

  View Document

• 

  Dr. Anil Takvani

  12 Apr 2021 09:01:06 AM

  I agree,  serial sonography is the best investigation in cases of UPJO like pre or post natal usg without symptoms or complications. 

  In your case there were multiple indicators where present;

  Nephromegaly on affected side 

  Pelvicalyceal dilatation of severe nature with parenchymal thinning 

  Nonuniform appearance of radioisotope in initial frames ( upto 4 minutes). Delayed CTT. 

  Reduced split function. 

  But if you still wait,  we do know many these asymptomatic cases can show improvement. It is also true many deteriorate and do not show recovery of lost nephrons/function.

  I agree , very appropriate case to have extensive and meaningful discussions...

  Thanks 

• 

  Venugopal P

  28 Apr 2021 10:43:39 AM

  Dear All,

  Gyanendra and Anil have taken us forward in our understanding of Renal Cortical Transit Time as more informative in predicting PUJO like obstructions. Gyanendra et al (2021) have provided a systematic review on the Utility of CTT in detecting prenatally detected PUJO like obstructions.

   https://www.indianjurol.com/article.asp?issn=0970-1591;year=2021;volume=37;issue=2;spage=116;epage=124;aulast=Sharma (PDF available)

  https://www.indianjurol.com/temp/IndianJUrol372116-1413453_035534.pdf

  Gyanendra has also indicated that measurement of APD in Supine and Prone will give us additional clue. Studying both together will help us in understanding who will require treatment and who could be followed up. The Algorithm he has provided in Uroacademy is well worth Following.

  Khalid Ismaili, Amy Piepsz (2013) in an excellent article on ‘Advances in Renography’ have indicated the problems associated with T1/2 as the yardstick to determine obstruction and they highlighted the need for better studies to indicate obstruction. The article is worth reading and understanding.

  https://link.springer.com/content/pdf/10.1007/s00247-012-2505-0.pdf

  The need to know which of these PUJ like obstructions are essential as delay in instituting treatment in those with obstruction will deteriorate the function, in some rapidly even. Boris Chertin et al in a study of long term followup of children followed up after Diagnosis of PUJO found that ~30% needed surgical intervention by 4 years of age indicating that missed obstruction can deteriorate function even after surgery. Hence undue delay should not be exercised in the management of PUJO like obstructions and a clear cut plan of management is needed. Going by a Differential of <40% may lead to delay in instituting treatment and at times could be detrimental to the improvement of Renal function.

  A recent article stating as first from the Nuclear Medicine Dept of AIIMS by Vishesh Jain* et al (2020) indicating that there is marked improvement in Renal Cortical Transit Time during postop assessment of PUJO.

  All these point out to the fact that Renal Cortical Transit time should be preferred over the existing T1/2 that we follow.

  With warm regards,

  Venu