Nephrectomy in a two year old child with PUJO
A two year old child came to me with complaints of failure to thrive i.e not gaining weight and a large lump in the abdomen. He aslo had high blood pressure (Hypertension). He was evaluated and was found to have a non functioning right kidney which had distended and became very big due to PUJ Obstruction. If this would have been diagnosed earlier when the baby was a few months old, the kidney function could have been preserved and the baby would have benefitted with pyeloplasty. But now ,the baby had to undergo removal of the right kidney after controlling the blood pressure with medicines. After the surgery, the baby did very well, started gaining weight and the blood pressure also normalised.
PUJ Obstruction
What is PUJ Obstruction ?
PUJ i.e Pelvi – Ureteric – Junction is where the kidney attaches to one of the ureters (the tubes that carry urine to the bladder). Pelviureteric junction (PUJ) obstruction is a restriction to the flow of urine from the renal pelvis to the ureter, which if left uncorrected, may lead to progressive renal deterioration. The blockage is always partial but the degree of a block may vary from minimal to severe. Mild cases usually don’t impair kidney function. Severe cases can cause significant impairment in kidney function. Because it impedes the flow of urine, there is resulting enlargement of the renal pelvis (hydronephrosis).
PUJ obstruction (PUJO ) is the most common cause (48%) of significant hydronephrosis detected on prenatal ultrasound or in newborns.
What causes PUJ Obstruction ?
Most often PUJO is congenital (present from birth). It can also occur later in life and can be caused by factors like compression by abnormal vessel, blockade by stone etc.
What are the symptoms of PUJO ?
Most infants (less than one year ) are asymptomatic, and most children are discovered because of their symptoms. The various ways in which babies and children present in PUJO are :
- Asymptomatic : diagnosed by antenatal scans / diagnosed incidentally
- Pain abdomen
- Abdomina mass
- Hematuria : passing blood in urine
- Urinary tract infection
- Hypertension : High blood pressure
What are the tests needed for the diagnosis of PUJO ?
- USG KUB : Ultrasound of Kidney , Ureter and Bladder
- DTPA / EC Scan : This test tells about the status of obstruction and the function of Kidneys
Do all cases of PUJO require surgery ?
If the PUJO is severe and leads to worsening of the kidney swelling and fall in kidney function, a pediatric surgeon will advise you for surgery.
What surgery is needed for PUJO ?
PUJO needs a surgery called pyeloplasty in which the junction of the kidney and the ureter is cut and sutured so that there is adequate drainage of urine. It can be done by oen surgery , laparoscopically (key hole surgery ) and nw with Robotic technique (Robotic Pyeloplasty).
When should you meet a Pediatric Surgeon ?
The moment the baby has any symptoms of the urinary system or one finds a swollen kidney (Hydronephrosis) on ultrasound, you must meet a pediatric surgeon. When an antenatal scan shows a swollen kidney , one must meet a pediatric surgeon right then. He will counsel you regarding further antenatal scans and the implications of hydronephrosis for the baby.
What happens if PUJO is not operated ?
If PUJO is not operated in time it will lead to complications like Hypertension (high blood pressure ) and mass in abdomen (hydronephrosis i.e swollen kidney ). If delaed it will lead to kidney damage i.e deterioration of function and if the function falls completely then the only option would be removal of kidney (nephrectomy ) rather than pyeloplasty which is a corrective surgery.