Babu Ramesh, Rathish Vishek Rajendran, Sai Venkata
Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India.
Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India.
J Pediatr Urol. 2015 Apr;11(2):63.e1-5. doi: 10.1016/j.jpurol.2014.10.007. Epub 2015 Mar 10.
Although initial conservative management is popular in the management of antenatally detected pelvi ureteric junction (PUJ) obstruction [1-3], several authors [4,5] have questioned this approach and expressed concern about failure to recover the function lost during expectant management following surgery. In this single center prospective study, we have compared the functional outcomes following early versus delayed pyeloplasty in SFU grade 3-4 PUJ obstruction.
Among those children, who presented between 2004 and 2013, with prenatal diagnoses of unilateral PUJ obstruction (n = 886), those with SFU grade 1 or 2 hydronephrosis on USG (n = 533) were excluded. In the remaining 353 children with SFU grade 3 and 4 hydronephrosis, 243 had obstructive pattern on radionuclide scan. After excluding those with severely impaired or supranormal split renal function (SRF), palpable mass, single kidney status, bilateral disease and associated other urological anomalies a total of 126 children were included in the study group. Parents who were unwilling for a frequent follow-up underwent early pyeloplasty, (Group I: n = 62) while the remaining underwent initial conservative management, with 3 monthly USG and nuclear scans (Group II; n = 64). In this group pyeloplasty was performed whenever there was deterioration in SRF >10%, or urine infection or pain during the follow-up. A standard open dismembered pyeloplasty was performed by the same surgeon in all patients. Radionuclide scan was performed at 1 year, at the same center using the same protocol, to assess final SRF and drainage. The functional outcomes were compared using student's t test and chi square test.
Group I comprised of 62 patients while Group II 64 patients. The mean age at pyeloplasty was 2.8 months in group I while 12.5 months in group II. There was no significant difference in the initial antero posterior diameter (APD) between the groups; 30.2 (±3.2) mm in group I and 29.6 (±3.7) mm in group II. At 1-year follow up after surgery, there was improvement in the APD, 16.8 (±4.2) mm in group I and 18.2 (±4.5) mm in group II, with no significant difference between them. In group I, the initial mean SRF was 34.1% (±6.4) and there was significant improvement (p = 0.01) in mean SRF to 37.2 (±7.1) at 1-year follow up after surgery. In group II, the mean SRF was 35.9 (5.7) initially and there was a deterioration to 32.6 (±5.5) before surgery (Figure). At 1-year follow up after surgery, there was a marginal improvement to 33.5 (5.6), however it was significantly lower compared to the initial SRF (p = 0.01). Compared to initial function, at 1-year follow up after pyeloplasty, SRF improved in significantly higher number of patients; 17/62 (27.4%) in group I while only 7/64 (10.9%) in group II (p = 0.03) (Table). There was significantly fewer patients with deterioration in final SRF at 8/62 (12.9%) in group I compared to 22/64 (34.4%) in group II (p = 0.03).
Although several publications [1-3] have reported functional recovery during initial conservative treatment of PUJ obstruction, in our study a large proportion of patients (80%) in Group II had loss of function during follow-up. This is probably because the study population included only SFU grade 3-4 with obstructive renogram. Several authors have expressed concern about irreversible loss of renal function during expectant management [4,5]. Findings of our study reveal that irrespective of initial SRF, early pyeloplasty in prenatally diagnosed SFU grade 3-4 PUJ obstruction leads to significant improvement of SRF, while delayed pyeloplasty leads to a marginal but, significant loss. This fact should be highlighted to parents so that informed decisions can be made regarding early versus delayed surgery.
尽管初始保守治疗在产前诊断的肾盂输尿管连接部（PUJ）梗阻的治疗中很常见[1-3]，但一些作者[4,5]对这种方法提出了质疑，并对手术后排尿期待管理期间丧失的功能未能恢复表示担忧。在这项单中心前瞻性研究中，我们比较了早期与延迟肾盂成形术治疗SFU 3-4级PUJ梗阻后的功能结果。
在2004年至2013年间就诊的、产前诊断为单侧PUJ梗阻的儿童（n = 886）中，排除超声检查显示为SFU 1或2级肾积水的儿童（n = 533）。在其余353例SFU 3和4级肾积水的儿童中，243例放射性核素扫描显示为梗阻型。在排除严重受损或超常分肾功能（SRF）、可触及肿块、单肾状态、双侧疾病及相关其他泌尿系统异常的患儿后 将126例患儿纳入研究组。不愿接受频繁随访的家长选择早期肾盂成形术（第一组：n = 62），其余患儿接受初始保守治疗，每3个月进行超声检查和核素扫描（第二组；n = 64）。在该组中，只要SRF下降>10%、出现尿路感染或随访期间疼痛，就进行肾盂成形术。所有患者均由同一位外科医生进行标准的开放性离断性肾盂成形术。术后1年在同一中心采用相同方案进行放射性核素扫描，以评估最终的SRF和引流情况。使用学生t检验和卡方检验比较功能结果。
第一组包括62例患者，第二组包括64例患者。第一组肾盂成形术的平均年龄为2.8个月，而第二组为12.5个月。两组初始前后径（APD）无显著差异；第一组为30.2（±3.2）mm，第二组为29.6（±3.7）mm。术后1年随访时，APD有所改善，第一组为16.8（±4.2）mm，第二组为18.2（±4.5）mm，两组之间无显著差异。在第一组中，初始平均SRF为34.1%（±6.4），术后1年随访时平均SRF显著改善（p = 0.01），达到37.2（±7.1）。在第二组中，初始平均SRF为35.9（5.7），术前恶化至32.6（±5.5）（图）。术后1年随访时，略有改善至33.5（5.6），但与初始SRF相比显著降低（p = 0.01）。与初始功能相比，肾盂成形术后1年随访时，第一组中SRF改善的患者数量明显更多；第一组为17/62（27.4%），而第二组仅为7/64（10.9%）（p = 0.03）（表）。第一组最终SRF恶化的患者明显少于第二组，分别为8/62（12.9%）和22/64（34.4%）（p = 0.03）。
尽管有几篇文献[1-3]报道了PUJ梗阻初始保守治疗期间的功能恢复，但在我们的研究中，第二组中很大一部分患者（80%）在随访期间出现了功能丧失。这可能是因为研究人群仅包括SFU 3-4级且肾图显示梗阻的患者。几位作者对期待管理期间肾功能的不可逆丧失表示担忧[4,5]。我们的研究结果表明，无论初始SRF如何，产前诊断为SFU 3-4级PUJ梗阻的患者早期肾盂成形术可显著改善SRF，而延迟肾盂成形术则导致轻微但显著的功能丧失。这一事实应向家长强调，以便他们能就是否进行早期或延迟手术做出明智的决定。
