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| Name | Laparoscopic Surgery for relieving Kidney Swelling in a child due to PUJ Obstruction: Expert opinion |
| Video Uploader | Video From Pediatric Urology & Hypospadias Channel |
| Upload Date | This Video Uploaded At 10-10-2024 05:30:05 |
| Video Discription | Laparoscopic Surgery for relieving Kidney Swelling in a child due to PUJ Obstruction: Expert opinion Pelviureteric junction obstruction is narrowing at the junction of the renal pelvis of kidney and the ureter which causes restriction of flow of urine from the kidney into the ureter. The block is usually partial hence some amount of urine may drain across the junction. This swelling seen as dilatation of renal pelvis increases over time. Over a period the functioning part of the kidney called cortex, or parenchyma may start decreasing leading to a decrease in the function of the kidney if not treated at early stage. Most of PUJ Obstructions are diagnosed during the antenatal scans done in pregnancy. If the antenatal scans show any hydronephrosis i.e swelling in the pelvis of the kidney without any swelling of the ureter or bladder, then PUJ Obstruction is the most likely diagnosis. This swelling can be seen as early as 18-20 weeks of pregnancy. A postnatal ultrasound at 7-10 days after birth is mandatory to assess the degree of hydronephrosis. If the postnatal scan shows hydronephrosis of more than 15mm then we do a nuclear renal scan which will confirm if there is an obstruction, and this renal scan also give us an idea about the relative function of the kidney. If missed in the antenatal period, children may present with a lump in the abdomen, or flank pain, urinary tract infections etc which are usually seen in older children with PUJO. Not all cases of antenatally diagnosed PUJ obstruction require surgery. A developing child has a very high urine output and hence in almost 70% of cases swelling may decrease after birth and surgery may not be needed. But it is critical to do follow up ultrasound and if needed renal scans to assess if kidney is not getting damaged and the swelling is decreasing. Surgery is required in PUJ obstruction if a. There is progressive increase in the HDN with thinning of the renal parenchyma on ultrasound. b. Renal scan shows decrease in the renal function with obstructed drainage. c. Child has symptoms such as flank pain, palpable lump in the abdomen, repeated urine infections or stone formation. The surgery to correct PUJO is called pyeloplasty. In this surgery we remove the abnormal blocked area and suture the normal area of the renal pelvis to the ureter. This establishes a good urine flow across the PUJ and has a very high success rate. During the surgery a thin tube which is called as DJ stent is placed across this junction with one end of the stent in the kidney and the other end in the urinary bladder. This DJ stent is typically removed 6-12 weeks later by a day care endoscopic procedure. Till 20 years back, all the children used to undergo open surgery for PUJ Obstruction. With miniature scopes, well trained pediatric urologists, majority of children with PUJ obstruction undergo laparoscopic pyeloplasty. At our centre we have been doing laparoscopic pyeloplasty for children as young as 4 months for last 18 years. For laparoscopic pyeloplasty, we make three small incisions of 5 mm and 3mm and place ports to see everything and perform surgery. The entire surgery is done through these three ports. The procedure is same as in open surgery but via long instruments which are inserted inside through the ports. The advantage of laparoscopic pyeloplasty are minimal post operative pain, early recovery and small scar. In the immediate post operative period some children may develop urine leak from the surgery site and that’s why we leave a drain for first 2-3 days. Drain is removed when the leak stops. There rarely may be bleeding which stops by itself in first week or wound infection which can be managed with by local wound care and antibiotics. The success rate of pyeloplasty at our centre is 98%. The first follow up after surgery is done after 8-12 weeks for DJ stent removal. Ultrasound is done one month after DJ stent removal and a renal EC scan is done 3 months after DJ stent removal. If ultrasound shows improvement, then one ultrasound is done at 6 months after the follow up ultrasound and yearly ultrasounds thereafter. EC scan is repeated only once after surgery. 2% children may develop recurrent obstruction and may need redo pyeloplasty. Laparoscopic pyeloplasty is feasible in PUJ obstruction in children beyond 3 months of age. Laparoscopic pyeloplasty is possible only if the surgeon has expertise in laparoscopy and good intra-abdomen suturing skills because it has a longer learning curve compared to open pyeloplasty. Once mastered it is better than open surgery because of good cosmetic results and less morbidity. Some doctors say that the swelling disappears once the baby urinates after delivery. This is not true. The swelling does not disappear once baby passes urine. Hence if antenatal scan showed any hydronephrosis please do visit a pediatric urologist and get your child checked at the earliest. |
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