Surgical management of ureteropelvic junction obstruction in children

Ureteropelvic junction (UPJ) obstruction is characterized by impairment in urinary flow as it travels from the renal pelvis to the bladder.

Sometimes UPJ obstruction is detected during an ultrasound before birth. Antenatal hydronephrosis, which may be caused by intrinsic UPJ obstruction, may be found by ultrasound as early as the second trimester of pregnancy. Other cases of UPJ obstruction may be discovered during an evaluation for signs and symptoms such as recurrent vomiting and feeding difficulties.

In older children, UPJ obstruction may be an extrinsic problem caused by compression of crossing vessels. Symptoms in these children can include nausea, vomiting, abdominal-flank pain, urinary tract infection and hematuria.

In lower grade obstructions, immediate surgery may not be necessary. If the obstruction is not causing loss of kidney function or pain, observation and monitoring may be indicated. Newborns should have renal ultrasound at age 2 weeks, and then every three months thereafter during the first year. A renal scan can be performed at age 6 to 8 weeks and repeated at age 1 year if ultrasounds are stable and baby is asymptomatic. Sometimes the condition resolves as the child grows.

Because prolonged high-grade blockage, particularly with infection, can be harmful to the kidney, surgery usually is necessary to prevent further kidney damage. Kidney stones, failure to thrive, recurrent urinary tract infections or loss of kidney function are indications for surgery.

Open and robotic-assisted pyeloplasty

Pyeloplasty, the removal of the abnormal segment of ureter, is the most common surgical treatment. During a traditional open pyeloplasty, the surgeon makes an incision below the rib cage in the upper abdomen or in the back. A nephrostomy tube or a ureteral stent or both are placed in the kidney. A small, plastic drainage tube may be placed near the repair as well.

When performed by experienced surgeons, robotic-assisted pyeloplasty now provides an effective, minimally invasive alternative to open pyeloplasty for the treatment of UPJ. The robotic-controlled surgical instruments are equipped with articulating tips and wrist mobility that improve precision, and the robotic camera gives 10 times magnification. These characteristics enhance a surgeon's ability to navigate challenging anatomy, to deftly perform microdissections and to precisely place sutures.

The advantages associated with the robotic approach include shorter hospitalization (overnight stay vs. two to five days), less pain and scarring, and shorter recovery. No external drains or stents are typically required for patients undergoing the robotic procedure. If a stent is needed, it may be left on a string so that it can be removed without additional surgery.

In addition to open and robotic-assisted surgeries for treatment of UPJ, Mayo Clinic pediatric urologists also offer consultation and surgical management for a wide range of pediatric genitourinary problems, including hypospadias, cryptorchidism, vesicoureteral reflux and urologic problems associated with spina bifida. In addition, Mayo Clinic specializes in a multidisciplinary approach to the treatment of more-complex urologic disorders, including exstrophy, intersex disorders, Wilms' tumor and bladder rehabilitation secondary to neurogenic lesions.

Points to remember

  • Pyeloplasty, the removal of the abnormal segment of ureter, is the most common surgical treatment for ureteropelvic junction (UPJ) obstruction in children.
  • When performed by experienced surgeons, robotic-assisted pyeloplasty now provides an effective, minimally invasive alternative to open pyeloplasty for the treatment of UPJ obstruction.
Apr. 24, 2014