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Common presentations
•  Intermittent abdominal and flank pain
– May be associated with nausea and vomiting

•  Incidentally found during investigation of
– Azotemia
•  Obstruction of a functionally or anatomically solitary
– Haematuria
– UTI, pyuria
Approach to Mx
•  Acute obstruction (urosepsis, azotemia with
solitary kidney, pain with UTI)
– Relieve obstruction
– Investigate once settled
•  No acute problem
– investigate
Goal of investigation
•  Determine anatomic site
•  Functional significance
•  PUJ obstruction is defined as functionally
significant impairment of urinary transport
from renal pelvis to ureter

•  Delayed emptying with dilated pelvicalyceal
system & normal ureter
•  If intermittent there may be normal imaging
between episodes
•  Ultrasound
– Good in neonates
– Demonstrates hydronephrosis
– Can distinguish between hydronephrosis and
multicystic kidney
– Useful if there is poor excretion of contrast of
nuclear isotope
•  Constrast CT
– Demonstrates hydronephrosis with site of
– Not quantitative
•  IVP
– Good concentration of isotope even with
decreased parenchyma (but not if multicystic)
– Quantitative, lasix, position
•  RGP
– Done at time of repair (to prevent introduction of
– Identifies anatomy (rest of ureter)
– Decompresses system
•  Percutaneous nephrostomy
– Can be done if too sick
– Allows pressure study
•  >15cm H20 suggests functional obstruction
– invasive
Indications for intervention
•  Acute obstruction
–  Sepsis
–  Pain
•  Impaired renal function
•  Progressive decrease in ipsilateral renal function
•  Stones
•  Recurrent infections
•  Observe if asymptomatic or physiological
significance not clear
•  Nephrectomy if nonfuctioning or multiple repairs
Endoscopic Interventions
•  Retrograde
– Hot cutting wire ballon endopyeloplasty
– Ureteroscopy and holmium laser
•  Antegrade if stones are present as well
•  Contraindications
– Stricture >2cm
– Infection
– Coagulopathy
Open or Lap
•  Pyeloplasty
– Open
– Laparascopic
•  If one endoscopic fails try open/lap or vice
•  Most commonly congenital
– May present at any age
– Aperistaltic segment of ureter
•  Spiral muscle replaced by longitudinal muscle or
fibrous tissue
•  Failure to propel a wave of urine into ureter
•  Lower pole arteries present in 1/3
– Functional significance unclear
– May cause obstruction of posterior to ureter
•  Intrinsic disease
– Infolding or kinks of ureteral mucosa or
– Retention of congenital folds
– External bands or adhesions
– Angulation or ureter at renal pelvis
•  Ureteral insertion carried proximally leading to
inadequate drainige of lower pelvis
•  Acquired
– Stricture is less common
•  Eg iatrogenic
– Reflux in kids may cause dilated, tortuous ureter
with kinks that may mimic radiological PUJ



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