Symptomatic versus asymptomatic pyeloplasties: A single institution review

Abstract

Introduction: Historically, pyeloplasties have been performed after symptoms and radiographic confirmation of an ureteropelvic junction obstruction (UPJO). However, with prenatal ultrasonography, the approach to patients has fundamentally changed. Increasingly, patients are diagnosed and treated before the advent of morbidity, based on imaging findings alone. However, optimum screening strategies and thresholds for intervention vary significantly, are controversial, and are not founded on outcome-based evidence. We examined all pyeloplasties performed at our institution and reviewed their indication for surgery. We hypothesized that, despite ubiquitous screening for UPJO, most pyeloplasties had been performed secondary to symptoms and did not benefit from antenatal screening. Methods: A retrospective chart review was performed of all pyeloplasties performed at the Stollery Children's Hospital, Edmonton, Alberta, over the past 8 years. Patients were categorized according to indication for surgery: symptomatic or asymptomatic. Results: Most (60%) of our pyeloplasties were performed for symptomatic indications. Furthermore, 12% of these patients had antenatally detected hydronephrosis that was thought to have resolved spontaneously during follow-up. Of our symptomatic patients, 37% were undergoing surveillance with the expectation for spontaneous resolution. Of the 29 patients who underwent pyeloplasty, 8 suffered a preoperative loss of function on renal scans; however, only 50% returned to within 90% of their original function. Conclusion: Despite active surveillance of antenatally detected hydronephrosis, most pyeloplasties at our institution were performed for de-novo symptoms. We believe that this simple observation reinforces that our current surveillance strategies are unable to predict and eliminate all morbidity from UPJO.

Percent improvement in renal pelvis antero-posterior diameter (PI-APD): Prospective validation and further exploration of cut-off values that predict success after pediatric pyeloplasty supporting safe monitoring with ultrasound alone

“…(Table 4). Complications related to the indwelling stent included stent colic/pain (4), UTI (2), formation of stones (2) and stent displacement (3). Mean time to all complications, excluding one rUPJO that presented 57 months post-operatively (after being lost to follow up), was 1.3±1.7 months, median 0.3 months (ranging from 0-6 months).…”

“…Indications for surgical intervention include worsening of hydronephrosis on serial ultrasounds (US), decrease in differential renal function (DRF) and/or prolonged drainage t½ time on renal scan, as well as the development of symptoms [3]. Ultimately, the goal of pyeloplasty is to preserve renal function as well as to minimize symptoms such as pain and infection [4].…”

Evaluating pediatric ureteropelvic junction obstruction: Dynamic magnetic resonance urography vs renal scintigraphy 99m-technetium mercaptoacetyltriglycine

“…Many urologists follow the sonographic diagnosis of hydronephrotic kidney and use declining renal function in functional imaging studies as an indication for surgery[ 6 ]. Asymptomatic patients with UPJO should only be treated if there is evidence of asymmetric function, functional deterioration, or hydronephrosis[ 4 - 7 ]. Identifying and surgically correcting UPJO in these patients before the occurrence of nephron loss is essential.…”