UPJO like USG with 55mm renal pelvic dilatation

An asymptomatic male patient of 5 weeks. 

Antenatal detection of right HN in third trimester. 
On examination normal. 
1st week USG,  35 mm right renal pelvic dilatation. 
5th week USG,  55mm pelvic dilatation. 
Ureter not dilated in any of these usgs.  Though bladder level usg pictures not available  
Attaching 1st week and 5th week usg images. 
Please opine? 
1. Do we need VCUG in this case? Why?  
2. Do we need to give AB prophylaxis? Why? 
3. Diuretic renal scan,  how early?  Why? 
4. Pyeloplsty if indicated,  how early? 

UPJO like USG with 55mm renal pelvic dilatation UPJO like USG with 55mm renal pelvic dilatation View Document


  • Dr. Anil Takvani
    Dr. Anil Takvani
    11 Feb 2020 07:59:17 AM

    I request urology trainees to respond to this post? 

    Also requesting teachers of training program to encourage trainees to write response to this post... 

  • Gyanendra Sharma
    Gyanendra Sharma
    11 Feb 2020 12:44:02 PM

    Dear Anil

    I usually get the AP diameter  as well as calyceal diameter in supine & prone position with bladder empty( on sonography)
    If the APD was 35 mm at 1 week I would have started chemoprophylaxis
    At 5 weeks with APD  being 50mm I would get a renogram done
    Further management would depend on the Differential renal function, cortical transit time and the APD in prone & supine position
    If pyeloplasty is indicated then I would do it immediately & not wait till the child is 3 months or older
    I am attaching my paper on  the same topic for the kind perusal & comments from the experts

    View Document

  • Dr. Anil Takvani
    Dr. Anil Takvani
    11 Feb 2020 01:57:14 PM

    Attaching diuretic EC scan received today. 

    Please discuss the issues I raised... 

  • Gyanendra Sharma
    Gyanendra Sharma
    11 Feb 2020 03:25:37 PM

    The differential function is 31%

    It is a DTPA study--likely to over estimate the function in this case
    Difficultu to comment categorcally about Cortical transit time but looks delyaed

    I would suggest pyeloplasty at the earliest
    As regards VCUG if the USG parameters are not suggestive of reflux--I would avoid it

    Though if you go by the recommendations of the Multidisciplinary committee on Management of Prenatallly detected PUJ--they suggest  VCUG in cases where the APD is > 35 mm

  • Dr. Anil Takvani
    Dr. Anil Takvani
    11 Feb 2020 05:06:38 PM

    This is diuretic EC renal scan... 


  • shriram joshi
    shriram joshi
    11 Feb 2020 08:35:46 PM

    Gynendra, how did you diagnose on seeing the scan it is DTPA and Tch Ec ?

    I don't think we should worry about mcug. Remember this is a 5 weeks old child and if not strongly indicated better avoided. Anyway I have not done mcug in a unilateral PUJ obstruction unless the usg defines dilated ureter, which in this case is not so.
    I agree with Gynendra, though not an emergency, but an early pyeloplasty is what I would do. 

  • Rahul Kapoor
    Rahul Kapoor
    11 Feb 2020 08:58:41 PM

    Why we dont want to wait for child to be 3 months ?

    In todays era even parents talk about Robotic, Laparoscopic pyeloplasty over open, does they really offer any benefit ?

  • Gyanendra Sharma
    Gyanendra Sharma
    11 Feb 2020 08:59:11 PM

    Respected sir

    It is written  on the renogram film that it is DTPA renogram

  • Dr. Anil Takvani
    Dr. Anil Takvani
    12 Feb 2020 06:18:00 AM

    Our radionuclide centre located at Rajkot is doing DTPA renal scan if we do not specify.

    As they are doing DTPA nearly in all by default DTPA is written on scan papers.

    On insistence of Prof. S S Joshi we enquired with centre, they informed us EC scan is very much possible and cost is same.. So, since last 2 years in suspected case of UPJO/VUJO we are doing diuretic EC scan.

    Regarding VCUG;

    Gyanandra is write , most of guideline insist to do VCUG in scenario under discussions. But I wander as to my understanding if reflux  is responsible for such a huge dilatation(secondary UPJO) then ureteric dilatation bound to be there and cannot be missed in serial USGs we do prior we send patient for renal scan or prior we operate these patients. And if both UPJO and VUR are coexisting as primary then in absence of ureteric dilatation even if we miss VUR, it want be clinically significant.

    Only thing we require is expert/experience paediatric sonologist who is doing most of your paediatric USGs, who is willing to do bladder level USG every time with full bladder along with renal level USGs with full bladder and empty bladder. He should understand you specific needs and should provide you images and not only the report. We need to talk with him frequently about what exactly we want and you will see within couple of months he can be expert like you. This can save many children with UPJO like asymptomatic patients from undergoing invasive and radiation involving procedure, VCUG.

    My next question is how many of you are comfortable in operating this case without doing IVP/CT IVP as I am seeing in OPD in last couple of years these patients come for opinion with CT IVP.

     Trainees please speak you mind...thanks

  • Dr. Isteaq Shameem
    Dr. Isteaq Shameem
    12 Feb 2020 08:38:25 PM

    Isteaq Shameem

    Very interesting case discussion,this scenario can bring different opinions
    Won't go for VCUG since no ureteral dilation on USG
    Will prefer Antibiotic prophylaxis 
    Won't advice IVP/CT since sonogram and DTPA are providing strong evidence of obstruction
    Will wait for another 3-4 weeks, get another USG if A-P increases do pyeloplasty 
    Thanks Dr Anil for this post

  • Ravindra Sabnis
    Ravindra Sabnis
    15 Feb 2020 03:32:40 PM

    If you read Campbell , their incidence of reflux is too high in unilateral puj obst.  Guidlines may tell to do MCU even if only unilat pujo on USG, we do not do it unless clear cut indications.  I concur opinion of SSJ sir of not doing MCU & we have not responded anytime. 

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    16 Feb 2020 09:42:29 AM

    I think, in this patient, USG & Isotope scan that is indicating Pyeloplasty is sufficient...

    Agreed, as ureter is normal, VCUG is not necessary.Even if it is done, we may get Gr I or II VUR .  However, that would not change the management.
    Obstruction in system is more harmful than Refluxing one.... We may not abstain few months for pyeloplasty unlike Anti-reflux  procedures.

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