Right HN- 21 years female patient

21 years female patient was investigated for right flank pain on and off since long before lockdown. 

She presented with 
Previous USG 
Diuretic renal scan 
Plain CT KUB 
Lab investigations normal 
I advised fresh USG and relavent lab investigations. 
Attaching all investigations...
Please discuss :
Is she investigated properly for your possible diagnosis? 
Further treatment? 

Right HN- 21 years female patient Right HN- 21 years female patient Right HN- 21 years female patient Right HN- 21 years female patient Right HN- 21 years female patient Right HN- 21 years female patient


  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    07 May 2020 07:58:23 AM

    Sir anatomy is not very clear in plain CT...for me it lookslike  either pujo with intrarenal pelvis or polycystic kidney...

    So..I would prefer either IVU or CT urogram..for proper anatomical details..n take a decision... correct me if I'm wrong sir..

  • Gyanendra Sharma
    Gyanendra Sharma
    07 May 2020 01:31:15 PM

    I would also agree with Dr. Mazumdaras regards that the photographs of the investigations are not clear

    But what I gather is 
    1. There is Right HN
    2. Function is 33%
    3. CTT seems be around 5 minutes
    4. Delayed images show significant retention of tracer
    I would do a RGP & then plan for further management

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    07 May 2020 01:52:57 PM

    Sharma sir...is ctt have also value in defining obstruction in Renogram for aduls?

  • Gyanendra Sharma
    Gyanendra Sharma
    07 May 2020 04:59:32 PM

    Dear Dr. Mazumdar

    I do not look at T 1/2 or drainage curves at all to diagnose obstruction
    For me CTT is a better indicator 
    T 1/2 is > 20 minutes in many cases and they never need surgery

  • Dr. Anil Takvani
    Dr. Anil Takvani
    07 May 2020 05:52:32 PM

    Thanks Gyanendra. 

    Patient has only one film of plain CT done at Rajkot.  Agree not a great film. 
    She has USG and diuretic renal scan suggestive of obstructive HN on right side. 
    Can it be retrocaval ureter? 
    Or as in CT film and in USG dilatation of ureter not seen and for that reason this is nothing but PUJO?
    Can you please write in detail what you want to see or rule out in RGP? 

  • Ravindra Sabnis
    Ravindra Sabnis
    07 May 2020 06:30:13 PM

    I feel, if USG is done properly, & isotope study gives idea of obstruction, then RGP is not needed. USG proper I mean, not just the static images, They can be misleading. all DD - whether cysts, whether retrocaval ureter, whether upper ureteric problem, or whether stone, can always be determined by good USG. In case doubt exists, (may be 5%) cases, CTIVP can always be done. Now low dose protocol CT are available. 

  • Prabir Basu
    Prabir Basu
    07 May 2020 09:14:01 PM

    As on today, is the directive of avoiding elective surgery in current pandemic still on? She has symptomatic pujo and is a surgical candidate , but I want to counsel her that I shall do the reconstructive surgery after some months , whence she reports with fresh CT IVP. If she has severe colic , fever with loin pain or hematuria in meantime , I may do an emergency stenting.

    Will I be wrong in the court of law?

  • Gyanendra Sharma
    Gyanendra Sharma
    07 May 2020 09:53:13 PM

    Dear Anil

    I would be surprised if it is retrocaval ureter
    My policy is to do RGP in all adults who present with PUJO and are undergoing surgery for the same
    I get a good idea of the anatomy, can plan my incision and also I place a DJ after RGP in all adults so there is no need to do antegrade stenting
    At times there are some surprises which are picked up on account of suboptimal preop radiological evaluations

  • Dr. Aadil Farooq
    Dr. Aadil Farooq
    08 May 2020 01:39:34 PM


    Although the given parameters appear to be sufficient for surgery for PUJ obstruction. 
    Pt. is symptomatic. 
    DTPA shows rising curve, Tmax, high T1/2. Depending on individual surgeon's choice, each parameter suggests obstruction. 
    Since the investigations are already four months old, I would like to have a good contrast CT KUB with IVP to delineate  the pelvis and ureter along with cortical thickness.
    This will help me plan my approach as well as need for RGP under same sitting.
    Sincere Regards, 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    08 May 2020 04:42:32 PM

    Dear Aadil,

    Why both?
    As you said obstruction is documented, Fresh USG has confirmed persistent gross HN with 30 mm pelvic dilatation and thinning of cortex, what you are seeking is more anatomical details.
    RGP or CT IVP, why both? Thanks

  • Dr. Aadil Farooq
    Dr. Aadil Farooq
    08 May 2020 06:53:23 PM

    Respected Sir, 

    I mean RGP only if there is some doubt in ureter beyond UPJ on CECT KUB. 
    We routinely don't do RGP.
    Otherwise CECT KUB is sufficient. 
    I couldn't see fresh USG findings with APD 30 mm.
    Thanks for guidance. 

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