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PELVIURETERIC JUNCTION OBSTRUCTION
Category: Urology
Abstract : Pelviureteric junction (PUJ) obstruction in adults Definition An
obstruction of the proximal ureter at the junction with the renal pelvis
resulting in a restriction of urine flow. Known as ureteropelvic junction
obstruction in North America (UPJO). Epidemiology Males >
females (5:2 ratio). In unilateral cases, the left side is affected more often
than the right.
Pelviureteric junction (PUJ) obstruction in adults
Definition
An
obstruction of the proximal ureter at the junction with the renal pelvis
resulting in a restriction of urine flow. Known as ureteropelvic junction
obstruction in North America (UPJO).
Epidemiology
Males >
females (5:2 ratio). In unilateral cases, the left side is affected more often
than the right. 10 - 15% are bilateral.
Aetiology
Congenital
-
Intrinsic: smooth muscle defect results in an aperistaltic segment of ureter at
the PUJ.
- Extrinsic: compression from lower renal pole vessel over which the
PUJ runs. It is unlikely that these vessels are the primary cause of the
obstruction. It is more probable that PUJO leads to a dilated PUJ and ballooning
of the renal pelvis over the lower pole vessels, which may thus contribute to,
but is not the primary cause of the obstruction.
Acquired
PUJ
stricture secondary to ureteral manipulation (e.g. ureteroscopy); trauma from
passage of calculi; fibroepithelial polyps; TCC of urothelium at PUJ; external
compression of ureter by retroperitoneal fibrosis or
malignancy.
Presentation
Flank pain precipitated by a diuresis (high
fluid intake; especially precipitated by consumption of alcohol); flank mass;
UTI; haematuria (after minor trauma). It may also be associated with
vesicoureteric reflux (VUR).
Investigation
Renal ultrasound shows
renal pelvis dilatation in the absence of a dilated ureter. IVU demonstrates
delay of excretion of contrast and a dilated pelvicalyceal system. Arrange a CT
to exclude a small, radiolucent stone, urothelial TCC, or retroperitoneal
pathology which may be the cause of the obstruction at the PUJ. MAG3 renography
with administration of frusemide to establish a maximum diuresis is the
definitive diagnostic test for PUJO. Radioisotope accumulates in the renal
pelvis, and following iv frusemide it continues to accumulate (a �€˜rising
curve). Many urologists perform retrograde pyelography to establish the exact
site of the obstruction, but they do this at the time of PUJ repair to avoid
introducing infection into an obstructed renal
pelvis.
Treatment
Surgery
Surgery is indicated for recurrent
episodes of bothersome pain, renal impairment, where a stone has developed in
the obstructed kidney, and where infection (pyonephrosis) has supervened. In the
absence of symptoms, consider watchful waiting with serial MAG3 renograms. If
renal function remains stable and the patient remains free of symptoms, there is
no need to operate.
Endoscopic treatment of a PUJO is called an
endopyelotomy (or pyelolysis). Various techniques have been described, but the
essential principle is the same full-thickness incision through the obstructing
proximal ureter, from within the lumen of the ureter down into the peripelvic
and periureteral fat, using a sharp knife or Holmium:YAG laser. The incision is
stented for 4 weeks to allow re-epithelialization of the PUJ. Relatively
minimally invasive. Generally not used for PUJO >2cm in length.
The
incision may be made percutaneously or by a retrograde approach via a rigid or
flexible ureteroscope, or by using a specially designed endoplyelotomy balloon
(the Acucise® technique).3
The presence of a combination of PUJO and a renal
stone that is suitable for PCNL is an indication for combined PCNL and
percutaneous endopyelotomy.
Success rates in terms of relieving obstruction:
percutaneous endopyelotomy range from 60 - 100% (mean 70%); cautery wire balloon
endopyelotomy 70%; ureteroscopic endopyelotomy 80%.
Pyeloplasty
-
Open: has success rates of 95%, and may also be used after endopyelotomy failure
or as a first line technique.
- Laparoscopic pyeloplasty has the advantage of
accelerated patient recovery.
- Common techniques include dismembered
pyeloplasty (also known as the Anderson - Hynes pyeloplasty: the narrowed area
of PUJ is excised, the proximal ureter is spatulated and anastomosed to the
renal pelvis), flap pyeloplasty (Culp), and Y-V-plasty (Foley).
Hit: 396 times
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