With the popularization of prenatal ultrasonography and the development of fetal surgery, the incidence of congenital pelvic ureteral junction effusion (UPJO) is a common malformation in the pediatric genitourinary system.
Common manifestations: common symptoms include abdominal mass, abdominal pain, hematuria, and urinary tract infection. Most of them are asymptomatic hydronephrosis, which is often found during screening. With the improvement and popularity of prenatal ultrasound technology, 30-50% of cases have been detected prenatally with fetal hydronephrosis. At present, we commonly see congenital hydronephrosis in pediatric patients.
Common tests: Ultrasound is the preferred screening method for hydrocele as well as a non-invasive test for postoperative review.
Ivu and ivp are valuable in the diagnosis of mild to moderate hydronephrosis. However, it is difficult to obtain good results in children because of intestinal gas.
Magnetic resonance urology (MRU) is a three-dimensional imaging of the urinary tract that is radiation-free, non-invasive, and does not require contrast injection. It is suitable for infants and children, severe renal dysfunction and iodine allergy. Disadvantages include inability to assess renal function and long scan time.
Nucleonuclide nephrogram (SPECT) is a supplement to the inadequate MRU examination. It uses markers that reach the kidney per unit time to estimate renal blood flow and absorption, secretion, and excretion functions.
CTU is a combination of rapid volumetric scanning, intravenous contrast, and computerized 3D reconstruction. Three-dimensional images of the entire urinary tract including the renal parenchyma can be obtained. It has the characteristics of high resolution, clear and intuitive image. With the advent of 64-layer spiral CT, it has become a new non-invasive examination method.
Classification of hydronephrosis
The American Academy of Pediatric Urology has established a simple, standardized grading method that is divided into four grades.
Grade 1: Mild separation of the renal pelvis;
Grade 2: dilatation of one or more calyces in addition to the dilated pelvis;
Grade 3: all calyces are dilated;
Grade 4: dilated renal calyces with thinning of the renal parenchyma.
Treatment.
Treatment principle: Remove the obstruction to preserve the affected kidney as much as possible and perform pyeloplasty.
Timing of surgery.
(1) Temporary observation and regular review For mild hydronephrosis without symptoms, surgery can be withheld and closely observed and regularly reviewed.
(2) Early surgery Any moderate hydronephrosis or cases under observation found to be aggravated by hydronephrosis and complicated by infection and stones should be operated as early as possible.
For school-age children with recurrent lumbar abdominal pain with urinary tract infection, ultrasound and imaging examination suggesting mild hydronephrosis or dilated upper ureter, often ureteral inflammatory polyps, should be operated as soon as possible.
(3) Neonatal hydronephrosis The timing and necessity of surgery is still debated. In recent years, our department has adopted the following approach: prenatally diagnosed fetal hydronephrosis should be examined by ultrasound within 3 days after birth, and those who still have significant hydronephrosis after birth should be further examined to evaluate their prognosis and decide on management measures.
For those with large renal pelvis diameter, severe hydronephrosis (grade 3 to 4), reduced relative renal function or very obvious symptoms, surgery should be performed as soon as possible. For those who have a mild degree of hydronephrosis, usually with a follow-up ultrasound once every 2-3 months, and whose hydronephrosis does not worsen during the follow-up, surgical intervention is not urgent and should be continued until the hydronephrosis decreases or disappears. At present, the youngest age in our department is 7 days old baby.
Treatment: Dissection pyeloplasty is the ideal procedure and is considered the “gold standard” for the treatment of PUJO.
Open surgery and laparoscopic surgery
Open surgery: The method is simple, straightforward, accurate anastomosis, and effective.
The incision for open surgery is the traditional lumbar incision, but the incision is long, while our department now often uses a small lumbar incision that is comparable to the minimally invasive incision.