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  • Dr. Anil Takvani
    Dr. Anil Takvani
    04 Mar 2020 07:52:27 AM

    We can safely observe this child explaining about possible symptoms of pain, UTI and secondary stone formation.

    I will do only USG six monthly to see any changes in renal size,renal pelvi-calyceal dilatation, renal cortical thickness and stone formation.
    Also will check urine and renal function periodically.
    If symptoms appears or any significant changes are seen in USG will recommend fresh diuretic EC scan.
    Will continue follow-up till age of 5 years as mentioned above.
    After 5 years patient can be discharged from regular follow-up. By that time they are almost highly educated for symptoms , so they have to report if symptoms appears. Or else get USG every year or two till adolescence. We can safely increase interval in asymptomatic patient.
    You can show USG pictures and renal scan function to relieve anxiety of parents.
    Last, diuretic curve do not hold much importance in this short of cases. 

  • Gyanendra Sharma
    Gyanendra Sharma
    04 Mar 2020 08:44:44 AM

    At present I do not think that the child needs surgical intervetion

    I look at couple of things in such cases
    1. The drainage pattern on sonography looking at AP diameter of renal pelvis & calyceal dilatation in supine & prone
    2. Differential renal function
    3. Cortical Transit time
    4. NORA--Normalized Residual activity on renogram in cases where the CTT is  around 3 to 4min
    5. 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 renograms
    Though 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 less

    I would observe the child doing USG every 6 monthly till the age of 6 years
    If there is not increase in hydronephrosis or change in drainage pattern on USG then my concern will be around adolescent age
    In 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 & NORA
    As regards follow up or evaluation using USG there sre some points which need emphasis
    1. USG to be done by the same sonologist using a standardized protocol . I mention what I follow
    2. Well hydrated patient
    3. Bladder empty--as a full bladder interferes with drainage of upper tracts
    4. Size of kidney to be looked for
    5. 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
    6. 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
    7. Parenchymal thickness at all poles
    This is our way of doing sonography in such cases

    As regards Prashant's question as to how to convince the parents-- I feel we have to educate them that hydronephrosis does not mean obstruction
    In fact many of out pediatrician colleagues also need to be educated about this concept

  • shriram joshi
    shriram joshi
    04 Mar 2020 07:24:02 PM

    I 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. 

  • Amilal Bhat
    Amilal Bhat
    05 Mar 2020 10:09:47 AM

    I will prefer conservative as discussed in detail.

    Amilal Bhat

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    05 Mar 2020 06:29:15 PM

    Yes, I also prefer conservative treatment... 
    Monitoring with USG renometry, ACR and isotope renogram.

    Additionally,  I would like to do  UDS.

  • shriram joshi
    shriram joshi
    06 Mar 2020 05:37:23 PM

    Dear 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 obstruciton 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    06 Mar 2020 05:41:58 PM

    I 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? 

  • Uday Sankar Chatterjee
    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. 

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