
Dr Prashant Mulawkar
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A case: Diagnosis & ...
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Posterior Urethra Ma...
15 Jan 2023 10:47:27 AMUPJO ?
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Gyanendra Sharma
04 Mar 2020 08:44:44 AMAt present I do not think that the child needs surgical intervetion
I look at couple of things in such cases- The drainage pattern on sonography looking at AP diameter of renal pelvis & calyceal dilatation in supine & prone
- Differential renal function
- Cortical Transit time
- NORA--Normalized Residual activity on renogram in cases where the CTT is around 3 to 4min
- I never look at T 1/2 values and drainage curve in cases of suspected PUJ obstruction as the reservior effect and absence of empty bladder leads to fallacious interpretation of these parameters
In this case USG shows good drainage in prone position( calyceal dilatation is not commented upon)The Differential function is well preserved in both the renogramsThough 1 minute images of renogram are not there the fist image showing activity between 1-3 minutes gives a fair idea that the CTT is 3 minutes or lessI would observe the child doing USG every 6 monthly till the age of 6 yearsIf there is not increase in hydronephrosis or change in drainage pattern on USG then my concern will be around adolescent ageIn couple of cases I have that the hydronephrosis which was stable till 5-6 years of age --increased during adolescence. Though I have to admit that this was seen before I started looking at CTT , USG drainage pattern & NORAAs regards follow up or evaluation using USG there sre some points which need emphasis- USG to be done by the same sonologist using a standardized protocol . I mention what I follow
- Well hydrated patient
- Bladder empty--as a full bladder interferes with drainage of upper tracts
- Size of kidney to be looked for
- AP diameter of the renal pelvis measured in supine & prone position in axial plane. It is important that the diameter is measured within the confines of the renal parenchyma. Often a sonologist not familiar with these cases measures the external pelvic diameter which can be fallaciously high
- Look for the maximal calyceal diameter in at least one the calyces--my sonologist feels that the upper pole is usually the one which can be meausred easily. This calyceal diameter is measured in both supine & prone position
- Parenchymal thickness at all poles
This is our way of doing sonography in such casesAs regards Prashant's question as to how to convince the parents-- I feel we have to educate them that hydronephrosis does not mean obstructionIn fact many of out pediatrician colleagues also need to be educated about this concept -
shriram joshi
04 Mar 2020 07:24:02 PMI agree with both Anil and Gynendra. This child needs only wait and watch policy, with followup ultrasounds as described above, and antibiotic prophylaxis.
Points to be noted for conservative treatment is mostly intra renal pelvis. Congenital Pelvi Ureteric Obstructions (PUJ obst. and please not UPJ obstruction. Urine flows from pelvis to ureter, let us not ape the americans!) is mostly an extra renal pelvis, and uncommonly both intra and extrarenal pelvis. The calyces are dilated, not significantly but the parenchyma is 7 mm which is good. There is no dilated ureter on the left side.Follow up usg shows some recovery of HN which I suspect will be normal a year later.SSJ -
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Uday Sankar Chatterjee
05 Mar 2020 06:29:15 PMYes, I also prefer conservative treatment...Monitoring with USG renometry, ACR and isotope renogram.Additionally, I would like to do UDS. -
shriram joshi
06 Mar 2020 05:37:23 PMDear Uday
What are the indications for a UDS in this child ? UDS is an invasive test for a child and has a potential for a febrile UTI. I feel it is unnecessary especially as this is only unilateral ? PUJn obstrucitonSSJ -
Dr. Anil Takvani
06 Mar 2020 05:41:58 PMI agree with Sir
Don't see any reason to go for UDM!Udayshankar Sit, can you please elaborate why you want UDM in this case?Thanks -
Uday Sankar Chatterjee
06 Mar 2020 06:29:00 PM.
In obstruction and reflux pathology, there may be some subclinical dysfunctional voiding due to inadequate synergy between autonomic (Detrusor) and somatic (Rhabdo), may cause elevated Pdet max and Pdet Qmax.
Dr. Anil Takvani
04 Mar 2020 07:52:27 AMWe can safely observe this child explaining about possible symptoms of pain, UTI and secondary stone formation.