CASE PRESENTATION

DR YASIR
31 years old female, married with four kids, a teacher in a
school run by local community.

• Left Pyelolithotomy in 2003

• Right PCNL in 2009
post op: hematuria
Rt: flank pain
dysuria
• Came in SIUT OPD in june 2010
Rt: flank pain
dysuria

examination: unremarkable
Labs: WNL (S.Cr: 0.64 mg/dl)
CT pyelogram: (June 10)
Atrophic left kidney with non-obstructing muliple
calculi, right kidney moderate HN with HU without any
evidence of obstruction, may be due to VUR.

Ultrasound KUB: (19-06-10)

Left atrophic kidney with multiple non-obstructing
calculi, right kidney moderate HN with HU, may be due to
VUR.
MCUG: (16-03-11)
Normal
X-ray IVP:
• normal functioning right kidney (however hydronephrotic).
• Slight delayed dye
excretion from left kidney.
• Small size left kidney.
• Normal cystogram
• No reflux
MAG-3 scan: (01-06-11)
Right kidney: 81%
Left kidney: 19%

 Right DJ stenting planned

• Right Dj stenting done on 26-01-12.
• She became symptoms free, except right flank pain during
voiding.
• Dj stent removad on 14-04-12.
• OPD follow ups:
symptoms- Rt: flank pain
Ultrasounds- mild fullness to normal kidney.
Serum Cr:- 0.7 to 1.1 mg/dl.
Urine C/S- No growth to MBG.

 Again develop right flank pain in July 2015 (moderate to

severe).
X-ray IVP:
• Right DJ stenting planned on 03-08-15.
• Right DJ stenting done on 21-12-15.
Plan: right pyeloplasty
• Right pyeloplasty planned on 21-12-15.
Date: 07-01-16 in admission OPD

 Presented in ER on 01-01-16
Fever with chills for 2 days (104*F)

• Inj: Sulzone 1.5gm BD started emperically

• Labs: Hb: 11.4 G% TLC: 24,000
PLT: 2,57,000 S.Cr: 1.20 mg/dl
Urine C/S: N/G

Examination: unremarkable (scar marks)

Ultrasound KUB:
CT Pyelogram: (05-01-16)
Mag-3 Scan: (04-01-16)
 :PELVIURETERIC JUNCTION OBSTRUCTION:
• functionally significant impairment of urinary transport from the
renal pelvis to the ureter.
• most cases are congenital, the problem may not become clinically
apparent until much later in life.
 Causes
• Congenital:
Intrinsic - presence of a peristaltic segment of ureter.
congenital ureteric stricture.
ureteral kinks or valves.
high insertion of ureter.
Extrinsic – lower pole aberrant vessels.
• Acquired:
Fibroepithelial polyp
Urothelial malignancy
Stone disease
Post inflammatory/Post operative
External compression
 Patient’s Presentation
• Antenatal
• Palpable flank mass
• Azotemia
• Abdominal or flank pain
• Hematuria
• Infection
• Hypertension
• Incidental finding
 Diagnostic Investigations
 Ultrasound:
Usually the first radiographic study performed.
May differentiate acquired cause of PUJO.
Mimic poly cystic kidney.
 X-ray IVP:
Not routinely performed.
Determine the anatomical site and functional significance of
obstruction.
May be normal during the painful episodes.
 CT scan:
Shows dilated renal pelvis and non-dilated ureter.
When I/V contrast given, finding includes delayed opacification of
collecting system, pyelocaliectasis, non visualization of ureter and
cortical thinning.
Also helps to exclude secondary cause.
 MAG-3 scan:
Is definitive diagnostic test
forPUJO.
It can quantify the degree of
obstruction and level of
obstruction.
Also provide split renal function.
 Retrograde pyelography:
This study is performed at the time of planned operation.
Confirms the diagnosis and establish the exact site of the obstruction.
Place DJ stent if B/L PUJO or patient in renal failure.
If unsuccessful placement of PCN is preferred.
> antigrade pyelography
> whitaker test
 Indication for surgery
• Symptoms associated with obstruction, impairment of overall
renal function or progressive impairment if ipsilateral function,
development of stone or infection, and hypertension.
• A symptomatic patients can be followed with regular
ultrasounds and MAG-3 scan.
• Non-functioning kidney may require nephrectomy (<15%)
• Procedure…….
 Options for intervention
 Endourological management:
percutaneous antigrade endopyelotomy.
percutaneous endopyelotomy and nephrolithotomy.
retrograde urteroscopic endopyelotomy.
 Laproscopic pyeloplasty
transperitoneal, retroperitoneal or robotic assisted.
 Open pyeloplasty
 Percutaneous antigrade endopyelotomy
• Historically it was only indicated in patients with PUJO with stones
and previously failed open procedure.
• Contraindications are long segment of obstruction (>2cm), active
infection and coagulopathy.
• Same PCNL technique.
• Lateral incisions are made with cold knife, holmium laser or cutting
balloon cathater.
• DJ stent placed.
• Success rate varies from 57% to 100%.
• Advise spiral CT angiography to rule out aberrant vessels.
• Complications are same that of PCNL.
• Percutaneous endopyeloplasty.
 Percutaneous endopyelotomy and
nephrolithotomy
• Same technique.
• Stone should be removed before endopyelotomy so that stone
fragments do not migrate into peripyeloureteral tissue.
• Laproscopic or robotic pyeloplasty with stone removal is best
alternative.
 Retrograde urteroscopic endopyelotomy
• Introduced in 1985 , with combine approach.
• It is done under vision without need of percutaneous access.
• Cost effective.
• Contraindications are long area of narrowing and renal stones.