Babu Ramesh, Suryawanshi Ashay Rajnikant, Shah Utsav Shailesh, Unny Ashitha K
Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research. Chennai, Tamil Nadu, India.
Indian J Urol. 2020 Oct-Dec;36(4):288-294. doi: 10.4103/iju.IJU_231_20. Epub 2020 Oct 1.
Bilateral hydronephrosis on prenatal ultrasound can be managed expectantly or with surgical intervention. The treatment strategies and outcomes are not clearly defined.
We conducted a retrospectively audit of outcomes of management of prenatally detected severe bilateral ureteropelvic junction obstruction (UPJO) in our institution.Patients with bilateral Grade 3-4 hydronephrosis were included. Those with complications like rupture, underwent bilateral intervention within 4 weeks; in the remaining, unilateral pyeloplasty was performed at 4-12 weeks. The contralateral renal unit was re-evaluated at a later date for further improvement or deterioration. All the patients were followed up with ultrasonography and renogram at 3 months, 6 months, and 1-year post operatively. The case records were analyzed for the resolution of antero-posterior diameter (APD) or the improvement in single-kidney glomerular filtration rate (s-GFR) in the operated units.
Over 15 years, 28 patients (56 renal units) had bilateral UPJO (male-to-female ratio = 13:1). Twelve units underwent neonatal intervention to tackle the complications (6 bilateral pyeloplasty), 17 units underwent early pyeloplasty, and 15 underwent late pyeloplasty. Twelve of the twenty-two (54%) contralateral units, which were stented/observed, resolved spontaneously. Receiver operating characteristics analysis revealed that those with initial APD <25 mm and initial s-GFR >35 ml/m were more likely to improve during the observation. Ten of the forty-four operated units (22%) failed to show an improvement. Units with initial s-GFR <10 ml/m had poor chance of postoperative functional recovery.
In neonates with bilateral UPJO, the worse affected kidney is operated first, as it still has the potential to recover. The contralateral milder UPJO unit is known to recover spontaneously following unilateral pyeloplasty. In those with bilateral Grade 4 UPJO and mass, bilateral pyeloplasty is feasible. Alternatively, unilateral pyeloplasty + contralateral cystoscopic retrograde stenting may prevent rupture or functional deterioration in the opposite kidney.
产前超声检查发现的双侧肾积水可采用期待治疗或手术干预。治疗策略和结果尚未明确界定。
我们对本机构产前检测到的严重双侧输尿管肾盂连接部梗阻（UPJO）的治疗结果进行了回顾性审计。纳入双侧3-4级肾积水患者。有破裂等并发症者在4周内接受双侧干预；其余患者在4-12周时进行单侧肾盂成形术。对侧肾单位在之后重新评估，以观察其进一步改善或恶化情况。所有患者在术后3个月、6个月和1年接受超声检查和肾图检查随访。分析病例记录，以观察手术侧前后径（APD）的消退情况或单肾肾小球滤过率（s-GFR）的改善情况。
在15年期间，28例患者（56个肾单位）患有双侧UPJO（男女比例为13:1）。12个肾单位接受了新生儿干预以处理并发症（6例行双侧肾盂成形术），17个肾单位接受了早期肾盂成形术，15个肾单位接受了晚期肾盂成形术。22个接受支架置入/观察的对侧肾单位中有12个（54%）自发消退。受试者工作特征分析显示，初始APD<25mm且初始s-GFR>35ml/m的患者在观察期间更有可能改善。44个接受手术的肾单位中有10个（22%）未显示改善。初始s-GFR<10ml/m的肾单位术后功能恢复的机会较小。
对于双侧UPJO的新生儿，先对病情较重的肾脏进行手术，因为其仍有恢复的潜力。已知对侧轻度UPJO肾单位在单侧肾盂成形术后可自发恢复。对于双侧4级UPJO且有肿块的患者，双侧肾盂成形术是可行的。或者，单侧肾盂成形术+对侧膀胱镜逆行支架置入术可预防对侧肾脏破裂或功能恶化。
