1. Pelvi-Ureteric Junction
Obstruction

2. Contents
 Embryology
 Incidence
 Etiology
 Pathogenesis
 Diagnosis
 Surgical management

4. Incidence
 1 in 1250 births.
 M:F = 2:1
 Bilateral in 10-36%
 Most common site of congenital ureteral
obstruction.

5. Etiology
 Two types of PUJO – Koff
 Intrinsic – most common (adynamic)
 Extrinsic – aberrant vessels, adhesive bands,
AVMs and Ostling folds.
 Intra luminal – ureteral valves, fibro-
epithelial polyps

6. Pathogenesis
 Chang and colleagues – deleted
Calcineurin B type 1 (CnB1) gene –
aperistalsis.
 Wang and colleagues – antagonized
BMP4 and Nogin protein – inhibition of
smooth muscle formation – adynamic
segment.

7. Clinical features
 Antenatal USG
 Postnatally
 Episodic flank pain
 Abdominal pain
 UTI
 Dietl crisis – cyclic abdominal pain with
vomiting.

8. Diagnosis
 Ante-natal : sonographic features
 Pelviectasis
 Normal amniotic fluid volume
 No ureteral dilatation
 Normal thickness of the bladder wall
 Normal cycling of the bladder

9.  Postnatal diagnosis
 USG Abdomen
 Highly accurate in the diagnosis of
hydronephrosis.
 Pelviectasis and caliectasis, absence of
ureterectasis, normal bladder cycling and normal
bladder thickness

10. Post natal diagnosis
continued...
 Cannot diagnose obstruction.
 Limiting factor - renal function

11. Renograms
 Technitium 99m renal scintigraphy
 Diethylene triamine pentaacetic acid(DTPA) –
neither secreted nor absorbed.
 Mercapto acetyl tri glycine (MAG 3) – secreted from
renal tubules
 Di-mercapto succinic acid (DMSA) – strong affinity
to renal tubular cells.
 Arbitrary threshold for surgical intervention –
35%

12.  VCUG – VUR is associated with PUJO in
9-14%.
 Magnetic Resonance Urography
 Doppler study – vascular imaging.

13. Surgical management
 Open technique
 Minimal invasive techniques
 Laparoscopy
 Endopyelotomy

14. Open technique
 Anaesthesia
 Position of the patient

15. Surgery...
 Incision
 Flank incision – tip of twelfth rib towards the
umbilicus
 Extra-peritoneal approach.
 External oblique, internal oblique, latissimus
dorsi and serratus posterior divided

16. Surgery...
 Diaphragm released from the tip of 12th
rib
 Peritoneum separated from Gerota’s fascia
 Self retaining retractor
 Kidney mobilized
 Ureter identified, looped, traced towards
kidney.

17. Surgery...
 Division of PUJ

18.  Anderson Hynes

19.  Foley Y-V plasty

20.  Spiral flap

21.  Excision of PUJ and spatulation of the ureter
 Ureteral stent/nephrostomy tube
 Anastomosis – lower lip of renal pelvis to the
spatulated apex of ureter.
 Posterior layer first - continuous or intermittent
 6-0 or 5-0 sutures
 Suturing continued until pelvis closed.

22.  Bladder catheter
 Perinephric drain

23. Laparoscopy

24. Laparoscopy
 Infants vs older children
 Pain
 Length of hospital stay
 Population based comparison of laparoscopic and open pyeloplasty in paediatric‐
pelvi ureretic junction obstruction - John Knoedler, Leona Han, Candace Granberg,‐
Stephen Kramer, George Chow, Matthew Gettman, Brittany Kimball, James Moriarty,
Simon Kim, Douglas Husmann

25. Thank You