
Gyanendra Sharma
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15 Jan 2023 10:47:27 AMPrenatally Detected PUJ Obstruction
Respected Seniors and Friends
Comments(5)
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Gyanendra Sharma
11 Apr 2021 11:00:46 AMI would agree with Dr. Anil that the system looks dilated and calyces ar dilated
I personally felt that the Cortical transit time was 3minutesHence a sonography was done at my center which showed marked decrease in AP diameter in prone position--the images and findings are attachedThe patient was advised regular follow up and the findings of serial USG are also attachedHis 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 questions1. Should we take Differential function of < 40% as an absolute criteria for surgery2. 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 urologyI personally feel that USG can be used more easily to decrease the need for repeating renogramsIn 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 doneOpinion 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 -
Gyanendra Sharma
11 Apr 2021 11:03:31 AMThe follow USG details are enclosed in the document attached
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Dr. Anil Takvani
12 Apr 2021 09:01:06 AMI 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 sidePelvicalyceal dilatation of severe nature with parenchymal thinningNonuniform 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 AMDear 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
Dr. Anil Takvani
11 Apr 2021 10:31:20 AMThanks for sharing case with required investigations.