University of Toronto
Severe ureteropelvic junction obstruction (UPJO) - like hydronephrosis in asymptomatic infants: To operate or not?
Abdulrahman Alsabban1,2, Todd Dow1, Dawn L. MacLellan1, Peter A. Anderson1, Rodrigo Romao1.
1Urology, Dalhousie University, Halifax, NS, Canada; 2Urology, King Abdulaziz University, Jeddah, Saudi Arabia
Introduction: Management of severe hydronephrosis in asymptomatic infants with an impaired drainage pattern on renal scan (UPJO-like) remains controversial. Our goal was to study the natural history of patients with UPJO-like hydronephrosis in a center where a conservative approach with objective indications for pyeloplasty is often used.
Methods: Retrospective chart review of patients undergoing a MAG3 renal scan in a tertiary children’s hospital over 16 years. Inclusion criteria were: asymptomatic infants with postnatal ultrasound showing SFU grade 3 or 4 unilateral hydronephrosis in the first 18 months of life, with impaired drainage on the renal scan curve. Exclusion criteria were solitary kidney, bilateral cases, presence of ureteric or bladder abnormalities. The primary outcome was pyeloplasty; age at and indication for surgery was also documented. A time-to-event analysis was performed.
Results: 747 patients with renal scan reviewed, 64 patients met inclusion criteria. Median follow-up was 40 months. 38% patients underwent a pyeloplasty at a median age of 21 months. Surgical indications were: decreasing renal function 38%, febrile UTIs 20% and flank pain 12.5%, and family preference 4%. Only 25% patients had surgery for worsening hydronephrosis. On time-to-event analysis, the risk of failure increased steadily until 36 months, when it reached 0.42 (95% CI 0.30-0.57) and plateaued after that (fig1). Median differential function on the affected side at last follow-up was 49.8% (IQR 47.8% - 52.7%) and 49% patients had improved to SFU grade 2 or less.
Conclusions: Most patients in this series underwent pyeloplasty for an objective indication before 3 years of age. Half of the patients had a marked reduction in the degree of hydronephrosis with preservation of renal function over time. Our data support a significant role for conservative management with close follow-up of patients with severe antenatally-detected hydronephrosis even in the setting of impaired drainage.
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