1 / 34

Ureteropelvic junction obstruction

Ureteropelvic junction obstruction. 報告者 : Intern 黃暉程 Supervisor: 主治醫師 : 邱元佑. Identification. Name: 黃小弟 Birth date: 05/31/03 → 19 d/o G2P2, NSD, Apgar score: 9’→10’ GA 41weeks, BW: 3000g(10~25%) BL: 52.5cm(10~25%), HC: 35cm(10~25%) DOIC(-), PROM(-).

Download Presentation

Ureteropelvic junction obstruction

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Ureteropelvic junction obstruction 報告者: Intern 黃暉程Supervisor: 主治醫師: 邱元佑

  2. Identification • Name: 黃小弟 • Birth date: 05/31/03 → 19 d/o • G2P2, NSD, Apgar score: 9’→10’ • GA 41weeks, BW: 3000g(10~25%) • BL: 52.5cm(10~25%), HC: 35cm(10~25%) • DOIC(-), PROM(-)

  3. Chief complaint: left abdominal mass for 2 days

  4. Present Illness GA 28-30wks Prenatal exam at 姚博琳’s clinic: Left hydronephrosis; Oligohydromino(-); Other abnormality(-) One mass over left abdomen noted by his mother 92/05/31 92/06/18 GA 41wks, NSD: Renal echo at 姚博琳’s clinic: Hydronephrosis is not identified Brought to Dr. 邱: A mass over LUQ palpable 92/06/16

  5. One 11x7cm soft mass over left abdomen; percussion: spongy-filling

  6. Abdominal mass ~ approach • Inspection, Percussion, Palpation

  7. Abdominal mass by age • Age-group 1 m~1 yr After 1 yr Newborns

  8. Differential diagnosis • Non-urologic Abdominal distention, pyloric stenosis, hepatosplenomegaly, intestinal obstruction, malignany, feces • Urologic Hydronephrosis, cystic disease, Wilms’ tumor, neuroblastoma, distended bladder

  9. Renal echo (Jun 18) Left severe hydronephrosis Cortex thickness: about 0.2cm AP diameter: 4.48cm (>1.5cm) Right moderate hydronephrosis No parenchyma involvement AP diameter: 1.2cm (>1cm) Imp: suspect left ureteropelvic junction obstruction

  10. Present Illness (1) VCUG (2) Antegrade pyelography Left PCN 92/06/18 92/06/27 92/7/2: discharge Admission PE LAB:CBC/DC, Biochemistry, U/A 92/06/19 92/06/23 (1) Left dismembered pyeloplasty (2) Pathologic Dx: Muscular hyperplasia and fibrosis, compatible with stenosis

  11. Indication of PCN • Obstruction with infection • Obstruction without infection • Stone disease • Prelude to endoscopic/ interventional procedures • Delivery of medications/ chemotherapy • Urinary leaks • Urinary diversion for hemorrhagic cystitis

  12. VCUG (Jun 23) Imp: No evidence of vesico-ureteral reflux

  13. Antegrade pyelography:Left UPJ stenosis is considered

  14. Present Illness Discharge! (1) VCUG (2) Antegrade pyelography 92/06/27 92/7/2 Left PCN 92/06/19 92/06/23 (1) Left dismembered pyeloplasty : UPJ obstruction, high insertion (2) Pathologic Dx: Muscular hyperplasia and fibrosis, compatible with stenosis

  15. Whitaker test during operation • Measure the pressure gradient between the pelvis & the bladder under fixed infusion rate • Less than 12 mmHg: no obstruction • Above 20 mmHg: obstruction • Pressure gradient was 14~15 mmHg → 1. intermediate 2. good compliance of pelvis and ureter

  16. Diagnosis Left UPJ stenosis

  17. Discussion UPJ obstruction

  18. UPJ obstruction • generally a congenital condition • male, left-sided lesions predominating • most frequently diagnosed cause of urinary obstruction in children • causes hydronephrosis which may damage the kidney

  19. Pathology Various interpretations- • Preponderance of longitudinal muscle fibers • Excessive collagen fibers in & around muscle bundles • Compromised or attenuated muscle bundles Our case: moderately lymphocytic infiltration & focal suppurative inflammation

  20. Symptoms & signs • Back or flank pain • UTI with fever • Hematuria • Abdominal mass→ infants }old children

  21. Diagnosis & tests • Prenatal Maternal pregnancy ultrasound: hydronephrosis • Postnatal Ccr, BUN, electrolytes, AP, DTPA, MAG3, VCUG

  22. Etiology • Intrinsic: Narrowed, dysfunctional or adynamic segments • Extrinsic: Upper ureter is angulated, kinked or compressed by bands or adhesions

  23. Intrinsic obstruction • mechanical: narrowed→ incomplete embryological ureteric bud recanalization; muscular invaginations overdevelop as flaps or valves • functional: adynamic or dysfunctional segment → inability to initiate, form or conduct peristaltic waves across the UPJ

  24. Extrinsic obstruction • vessel or fibrous band may pass anterior to the pelvis & ureter: most common • may secondary to intrinsic disturbance which produces pelvic overdistension & rotation • high insertion of the ureter into the pelvis

  25. Extrinsic ~ High insertion

  26. Whitaker test: flow across UPJ obstructions Pressure dependent Volume dependent Intrinsic obstructionExtrinsic obstruction

  27. Treatment • influenced by renal function, infection • surgical correction of the obstruction • infants: dismembered pyeloplasty • adults: percutaneous or endoscopic technique • a nephrostomy stent is placed to drain urine until the patients heals

  28. Surgical indication • Bilateral UPJO • Palpable mass • Unilateral UPJO with hydronephrosis Grade 4 (Massive pelvic & calyceal dilatation with thinned parenchyma); DTPA < 30% or worsen > 10% in f/u

  29. Author and Year Patients/Kidneys Success (%) Poulsen et al, 1987 35 100 O’Reilly, 1989 30 83–93 MacNeily et al, 1993 75 85 Shaul et al, 1994 32/33 (<2 mo old) 97 30/33 (>2 mo old) 93 Salem et al, 1995 100 98 McAleer and Kaplan, 1999 79 90 Austin et al, 2000 135/137 91 Houben et al, 2000 186/203 93 Prognosis ~ pyeloplasty

  30. Prognosis ~ pyeloplasty

  31. Expectantions • Rapid decompression of the kidney immediately following birth can substantially improve kidney function in an infant with UPJ obstruction diagnosed before the child is born. • Most patients do well with no long-term consequences

  32. Complications • Permanent loss of kidney function-renal failure • require dialysis at some point in their lives as a result of this problem

  33. Thanks for your attention!

More Related