What is Ureteropelvic Junction Obstruction?

Ureteropelvic junction (UPJ) obstruction is a partial or complete blockage at the point where the organs that contain urine (the kidney) are connected together with the tube that carries it to the bladder (the ureter).

The blockage can vary from extreme to minimal. Mild cases typically do not harm the kidney or affect its function, but they can predispose the infant to infections of the urinary tract. Severe cases can cause significant kidney damage.

Ureteropelvic Junction Obstruction Symptoms and Diagnosis

Obstruction of UPJ is frequently diagnosed during prenatal ultrasound, while examining the swollen kidney. Symptoms indicative of UPJ obstruction include hematuria (blood in the urine), urinary tract infection, kidney failure, kidney stones, and abdominal pain for those who develop later or are not observed at birth.

Although the most common type results from a narrowing of the ureter as it develops in fetal development (usually due to an abnormality in muscle development surrounding the UPJ), UPJ obstruction may also occur later in life and may be caused by other factors, including inflammation, kidney stones, scar tissue, enlarged blood vessels or a tumor compression of the ureter. Diagnostic tests help assess the degree of obstruction to UPJ and whether surgery is necessary.

Treatment for Ureteropelvic Junction Obstruction

If the obstruction is mild, the correction is usually left to itself. Antibiotics may be used to avoid infection, and a renal ultrasound is tracked to the infant every 3-6 months. Owing to the potential for damage to the kidney, more serious cases appear to require pyeloplasty, a surgical procedure that eliminates the blockage and reconnects the ureter and the renal pelvis. The success rate reaches 95 percent, and the operation can also be done laparoscopically. Also after positive repair the child continues to be treated to ensure proper functioning of the kidney.

Laparoscopic Pyeloplasty

Compared to traditional open surgical technique, laparoscopic pyeloplasty results in substantially decreased post surgery discomfort, shorter hospital stay, quicker return to work and ability to perform day-to-day activities, and more desirable cosmetic results and results comparable to the open method. 

A ureteropelvic junction obstruction (UPJ) caused due to stone or prior surgery, horseshoe kidney, or a blood vessel causing kinking of ureteropelvic junction, or due to stone impaction in the upper part of the ureter, then the patient must undergo laparoscopic pyleoplasty.

Preparation:

The medical history including X-rays, CT scan, MRI, ultrasonography, etc. will be reviewed thoroughly, followed by a physical examination. An assessment of the feasibility of the surgery will be done. After assessment of need for surgery, following investigations will be done:

  • Physical examination
  • ECG
  • Hematological investigations including coagulation profile
  • Blood chemistry profile and urine analysis

Based on comorbidities (existing diseases), the doctor may ask to stop certain medications, which may obstruct the surgery.

The patient is asked to follow certain instructions which include dietary controls, medications, etc.

Surgery:

Laparoscopic pyeloplasty is performed with a general anesthetic. The average service duration is 3–4 hours. The surgery is done by 3 incisions made in the abdomen, low (1 cm). By these keyhole incisions, a microscope and small instruments are placed into the abdomen, allowing the surgeon to repair the blockage / narrowing without inserting his hands in the abdomen.

After the laparoscopic surgery, the patient is shifted to the recovery room and if the recovery room stay is uneventful, the patient is then shifted to ward. The normal length of hospital stay is around 1 to 2 days.

The patient is kept on intravenous support initially and the next day if the patient is able to tolerate orally, the patient is given an oral diet.

After surgery, the patient may experience pain which is usually controlled by intravenous analgesics. Nausea is controlled by antiemetics. Shoulder pain due to carbon dioxide subsides usually after 2 to 3 days.

Urinary catheter is usually removed within 2 days of surgery and drain may be kept in few cases and removed on follow-up visit with the doctor.

Breathing exercises need to be performed to recuperate well and to prevent lung related complications. Stockings are worn and patients are allowed to ambulate at the earliest to prevent thrombus formation in the legs. Constipation is managed with conservative means.

Post discharge from hospital:

Pain: The patient may still feel pain, which is managed conservatively.

Bathing: Bath can be taken but care should be taken to avoid wetting of the wound area (which should be kept dry, or in case it gets wet, padding should be done). 

Sutures (Stitches): Dissolvable sutures are used for suturing. So they will dissolve by themselves in 4 to 5 weeks. 

Physical activity: Walking should be done at home, sitting for long periods or lying down in bed should be avoided. Heavy weight lifting should be avoided and heavy exercises or swimming should be avoided till advised by the doctor. Patients can expect to return to normal activities by 3 to 4 weeks.

Stent removal: Stent is removed during the follow-up visit with the doctor, using a cystoscope. This may cause urinary urgency or flank fullness, which recovers over time.

What are the expected complications?

Infection and pain can occur occasionally at the wound site. There could be a hernia in the incision site that will need further care. There is a small risk that the surgeon may need to continue with the open repair if he finds complications such as bleeding during the procedure. Even a blood transfusion can very rarely be necessary. Injury to organs / blood vessels near the heart, which then involve conversion to open surgery, are very rare complications.