A guide for families about ureteropelvic junction obstruction
What is ureteropelvic junction?
Urine produced by the kidneys is first collected in a pool called the renal pelvis and then transported to the bladder (urinary bladder) by tube-like structures called ureters. The stenosis that develops at the junction of the renal pelvis and the ureters is defined as ureteropelvic junction obstruction. With the disruption of the flow of urine from the kidneys to the ureter, urine accumulates in the renal pelvis and causes enlargement called hydronephrosis. If not intervened, deterioration or complete loss of kidney functions may develop over time.
What are the causes?
The exact cause of this disorder is unknown. The stenosis is thought to develop during the formation of the kidney in the prenatal period. This situation can sometimes occur because one of the vessels of the kidney passes over this junction and narrows the junction. In older children and teenagers, this condition may develop due to a scar tissue in the ureteropelvic region, after infection, previous treatments, or stone development.
How often does it occur?
It is the most common cause of urinary tract obstruction in children. This problem occurs in 1 in 1500 children.
What kind of complaints does the patient have?
It can be noticed in early pregnancy follow-ups. Flank pain, bloody urine (hematuria), swelling or mass in the abdomen, kidney infection, insufficient development of the baby, urinary tract infection and vomiting may occur.
How is it diagnosed?
Ultrasonography during pregnancy shows kidney problems before the baby is born. In patients presenting after delivery or with complaints, blood biochemistry (urea, creatinine, electrolytes), kidney nuclear studies (scintigraphy), voiding films (voiding cystourethrography), computerized tomography and intravenous pyelography examinations are performed when necessary.
How is the treatment done?
It is easily noticed during pregnancy due to the prevalence and frequency of prenatal ultrasounds in recent years. It can be noticed after birth in some children. In cases where the obstruction is very severe and damages the kidney, surgery may be required early in life. In most children, there are milder cases that need to be monitored, and when surgery can be delayed until later in life. Some patients do not require surgical treatment.
Classical ureteropelvic junction obstruction surgery; It is based on the removal of the narrow ureteropelvic junction and re-opening the ureter to the intact pelvic tissue, which is called pyeloplasty. Pyeloplasty can be performed by open surgery or by closed methods (laparoscopic or robotic).
- Open Pyeloplasty: It is the gold standard method in the treatment of symptomatic children such as recurrent flank pain and urinary tract infection. The chance of success with a single operation is 95%. In small babies, a small lateral abdominal incision of 4-5 cm is usually made.
Thenarrow and defective structure that prevents urine from being taken is removed and healthy tissues are joined together
Since almost all suture materials to be used are soluble, there is no need to take stitches. A rubber tube in the form of a soft band called “Penrous drain” can be removed from the wound to remove the fluids that may accumulate during or after the surgery. The penrous drain is easily and usually painlessly removed just before the child is discharged from the hospital. Depending on the surgeon's preference, in some cases, a tube called a "stent" may be placed in the ureter to prevent closure of the ureter and to provide urine drainage. In addition, a Foley catheter is placed through the urinary tract to empty and relieve the kidney and urinary bladder after the surgery. During this time, your child's urine is collected in a bladder attached to a catheter.
- Laparoscopic and robotic pyeloplasty (closed method): These arerelatively new treatment methods. In these approaches, the body is entered with a camera and other instruments placed through 3-4 small holes to be opened in the abdominal wall instead of a skin incision.
The surgical method, approximate operation time and success rates are the same as in open surgery. Advantages of closed methods: Small skin incision, larger and clearer image can be obtained under optical magnification, less postoperative pain, shorter postoperative hospital stay (1-2 days), faster recovery and return to normal life.
What are its complications and how are they treated?
The prognosis is generally quite good after pyeloplasty operations in children. After surgical correction, recurrence is almost never observed. Rarely, wound infection and bleeding from injury to major renal vessels may occur and blood transfusion may be required. Since the collecting duct is sutured during the operation, urine leakage from this area outside the kidney may occur (1%). This leak usually stops on its own. Less frequently, intestinal, liver and spleen injuries may be encountered. Although there is a risk of absorbing the carbon dioxide used to create the working area during laparoscopic surgery and accumulating under the skin, lungs, and intestines, it can be corrected with appropriate treatments.