Ureteropelvic junction obstruction (UPJO)

Ureteropelvic junction (UPJ) obstruction is defined as restriction of urine flow from the
pelvis into the proximal ureter with subsequent dilatation of the collecting system. It is the
most common cause of neonatal hydronephrosis. It has an overall incidence of 1:1500 and
a ratio of males to females of 2:1, more likely to occur on the left side and is bilateral in
10% to 40%.

Etiology:

1-Intirinsic: Most often, the UPJO in newborns and infants is caused by an intrinsic
narrowing of the UPJ. The typical finding is a narrowed segment of the UPJ with an
interruption in the development of the circular muscular fibers. This leads to a functional
discontinuity of the muscular contractions and ultimately to insufficient emptying of the
renal pelvis.

2- Extrinsic: caused by an accessory vessel to the lower pole of the kidney, with the ureter
kinking over the lower pole vessel

Diagnosis

1- Ultrasound: Nowadays, most hydronephrotic kidneys have already been diagnosed

prenatally. Ultrasound diagnoses UPJO by detecting dilatation of renal pelvis but
normal ureter.
2- Intravenous pyelogram (IVP):
3- Diuretic renography: to assess differential renal function.

Treatment

Symptomatic obstruction (recurrent flank pain, urinary tract infection) requires surgical
correction ( pyeloplasty)

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 Anomalies of the lower
Urinary Tract

Vesicoureteral Reflux
Definition:
Retrograde flow of urine from the bladder to the upper urinary tract.

Etiology of Vesicoureteral Reflux

Primary Reflux
primary reflux represents a congenital defect in the structure and function of the
ureterovesical junction..
Secondary Reflux
-Bladder dysfunction e.x neurogenic bladder.
-Bladder outlet obstruction e.x posterior urethral valve.

Grading of Reflux: by the voiding cystourethrogram

GRADE DESCRIPTION
1 Into a nondilated ureter.
2 Into the pelvis and calyces without dilatation.
3 Mild to moderate dilatation of the ureter, renal pelvis, and calyces.
4 Moderate ureteral tortuosity and dilatation of the pelvis and calyces
5 Gross dilatation of the ureter, pelvis, and calyces and sever ureteral tortuosity

Complication of VUR:

-Infectious pyelonephritis: reflux facilitates the ascension of microorganisms from the

bladder to the kidneys.
-postpyelonephritic scarring:
-Hypertension.: VUR is the primary cause of hypertension in children.
-Renal Failure: high grade bilateral VUR may cause renal failure by back pressure and
infection.

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Diagnosis of Vesicoureteral Reflux

The voiding cystourethrogram (VCUG): the gold standard for reflux detection.

Renal ultrasonography: it is used for serial follow-up of renal growth and development .
Ultrasonography also images the degree of corticomedullary differentiation in the kidney.
Loss of corticomedullary differentiation, or an increase in the overall echogenicity of the
kidney is associated with some degree of renal functional impairment.

Renal Scintigraphy: The main test for scar detection.

Management of VUR:
Medical Management:
- Spontaneous resolution of reflux is very common (90% for grade 1, 80% of grade 2 ,
50% for grade 3 , 25% for grade 4 and 5% for grade 5).
-. The classic approach is daily low-dose prophylactic antibiotic suppression of infections
as the first line of treatment under the principle that every case of reflux should be offered
time to resolve spontaneously. It is reasonable to wait until approximately 5 years of age
assuming no intercurrent breakthrough infections occur. Beyond this age, it is commonly
believed that the kidneys become less prone to scarring after pyelonephritis.
Endoscopic Treatment of Vesicoureteral Reflux: use of injectable bulking agents to
narrow the ureteral orifice, thereby preventing vesicoureteral reflux.
Surgical treatment: by ureteric reimplantation, indicated in patient with recurrent
breakthrough infections.

Posterior Urethral Valves

It is mucosal fold at posterior urethra causing varying degree of obstruction to voiding
without interfering to retrograde catheterization. The classic posterior urethral valves
occur only in males.

Pathophysiology: The effects of congenital obstruction of the urethra are reflected in

the entire urinary tract above the level of obstruction.
-Bladder: hypertrophy and hyperplasia of the detrusor muscle along with increased
connective tissue. The bladder neck is rigid and hypertrophied.
-prostatic urethra: High voiding pressures distend and thin the prostatic urethra.
-Ureter: The ureteral wall is thickened and the lumen massively dilated.

-Kidney: renal injury is caused by persistent high pressure.

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Clinical Presentation: it depends on age of patient and degree of obstruction.

In utero: today, most patients with posterior urethral valves are diagnosed with prenatal
ultrasound. The observation of marked hydroureteronephrosis, a distended bladder, and a
thickened bladder wall and oligohydramnios in utero strongly support the diagnosis of
valves.

Newborn: usually presents with signs of severe systemic illness such as failure to thrive,
lethargy, and poor feeding. The infants may be pale and have poor muscle tone.
Examination of the abdomen may reveal masses due to hydroureteronephrosis and a
distended bladder.

Older Children: present with urinary tract infection and difficulty in urination with poor
urinary stream.

Diagnosis:
Ultrasound: The classic ultrasound findings in patients with valves include bilateral
hydroureteronephrosis, distended bladder, dilated posterior urethra, and a thickened
bladder wall.
Voiding Cystourethrography: The voiding cystourethrogram (VCUG) remains the most
important study in diagnosing posterior urethral valves because it defines the anatomy and
gross function of the bladder, bladder neck, and urethra.
Cystoscope: for direct visualize the valve and also therapeutically by valve fulgration.

Laboratory Evaluation: serum Creatinine and blood urea to assess renal function.

Management:
Bladder Drainage: Initial management of all patients with posterior urethral valves
requires the immediate urinary catheter drainage from the bladder.
Valve Ablation After successful initial bladder drainage and when the patient’s medical
condition has stabilized, the next step is to permanently destroy the valves by using
pediatric resectoscope with a hook or cold knife to incise the valves.