Ureteropelvic Junction Obstruction Treatment in Cuttack: Causes & More

Ureteropelvic junction (UPJ) obstruction is a condition that is characterized by a blockage at the ureteropelvic junction (the point where the pelvis of the kidney meets the ureter). The ureter is a thin long, tube-like structure that carries urine from the kidney and drains it into the bladder. 

The obstruction can either be congenital (present since birth), secondary to trauma, or a change in body shape as you age. The blockage slows or halts the urine flow, which may eventually increase the pressure within the kidney, forming scar tissue at the obstruction. Excess pressure within the kidney can damage it and impair its function.

Ureteropelvic junction (UPJ) obstruction is a blockage in the renal pelvis of the kidney (area at the center of the kidney), a funnel-shaped part that collects urine. The urine is then drained into the bladder through peristalsis (involuntary contraction and relaxation of the muscles around). 

Any obstruction in this junction, present congenitally or secondary to trauma, can create urine buildup within the UPJ, increasing the pressure inside the kidney. 

This dilates the kidney (hydronephrosis) and causes permanent damage, impairing the renal (kidney) function. Ureteropelvic junction obstruction in infants usually does not require treatment since it resolves on its own within the first 18 months of life. 

However, surgery may be recommended in infants if the urine flow does not improve. Medical treatment has no role in adults, and surgical intervention is required in UPJ Obstruction. The surgical methods include:

• Endopyelotomy: A procedure that involves an endoscope (tube with a camera and light source, and a surgical knife attached at the tip) inserted within the ureter to cut away the obstructed part.
• Open Pyeloplasty: A traditional method that involves a single large incision (cut) to remove the scar tissue.
• Endopyeloplasty: The procedure involves using a telescope or a balloon with an electric wire attached to it to remove scar tissue.
• Laparoscopic Pyeloplasty: A minimally invasive procedure that involves inserting a laparoscope (thin tube with a light source and camera that captures images and projects them on a large screen to guide the surgeon) to remove the scar tissue. 

Ureteropelvic junction obstruction is commonly seen among infants that may be present congenitally. The structures of the kidney and ureter fail to form normally as the fetus develops. The obstruction can be easily detected in an ultrasound scan where the affected kidney appears swollen (hydronephrosis). This is due to the fact that the presence of UPJ obstruction causes more than normal production of urine, which pools around the kidney pelvis, thereby abnormally enlarging the kidney. 

In some cases, UPJ obstruction can also occur as an inherited condition (running in the family and passed down through generations).

When UPJ obstruction occurs in adults, it is generally due to:

• A scar tissue
• Kidney stones
• Persistent upper urinary tract infection
• Previous treatment or surgeries causing a blockage
• Compression of the UPJ by a blood vessel
• Irregularities in the fibrous bands around the ureter
• Renal trauma or injury

The symptoms of UPJ depend on the age of the patient and differ in adults and children.

Infants: 

Most often, the obstruction in infants can be identified through routine pregnancy scans that present with hydronephrosis (abnormal swelling of the affected kidney). 

Other potential symptoms include:

• Blood in the urine (hematuria)
• Failure to thrive (poor growth)
• Urinary tract infection accompanied by fever, foul-smelling urine, poor feeding, vomiting, and discomfort while urinating.

Older Children & Adults:

• Severe flank pain (pain in the side of the abdomen), that intensifies on consuming liquids, which adds to the pooling of the urine around the UPJ and increased renal pressure.
• Presence of abdominal mass
• Repeated kidney infections
• Blood in the urine (hematuria)
• Nausea and vomiting
• Swelling (edema) of the face, especially around the eyes
• Urinary tract infections

You may need to undergo various tests to confirm the diagnosis and evaluate the severity of the condition.

Prenatal Ultrasound:

• The obstruction can be detected in the developing fetus during routine pregnancy scans as hydronephrosis (kidney swelling).

Renal Bladder Ultrasound (RBUS):

• This is performed once the baby is born if hydronephrosis is detected prenatally.
• It helps to evaluate how serious the hydronephrosis is.

Voiding Cystourethrogram:

• It is a special type of X-ray where your child's bladder will be filled with a liquid containing iodine. 
• As the bladder fills up and your child urinates, the liquid flow will be visible on X-ray images.

MAG III Renal Scan:

• This helps to measure the difference in the function between both kidneys and evaluate the degree of obstruction.
• A radioactive isotope will be injected into your child's veins, and a special camera (gamma camera) will rotate around to take images of the kidneys to visualize how well the filtering and draining take place.

Blood Tests:

• Blood and urine samples will be taken to test for BUN (blood urea nitrogen) and creatinine levels to check how well the kidneys are functioning.

Urinalysis And Culture:

• These tests indicate the presence of blood or protein in the urine and evidence of urinary tract infections (UTIs).

Intravenous Pyelogram:

• A special dye is injected into the bloodstream, which is later traced on X-ray as it flows through the kidneys and ureter.

CTU & MRU Scans: 

• Can accurately show the exact location of the UPJ obstruction and helps diagnose multiple urologic problems.

Ureteropelvic junction obstruction in infants does not require treatment since they can outgrow the condition within 18 months of life. However, antibiotics may be prescribed to prevent infection. Persistent obstruction with poor urine outflow and increased risk of kidney damage require surgical intervention. Medical treatment is not recommended in adults, and surgical intervention is necessary to treat UPH Obstruction.

The different surgical methods are as follows:

Pyeloplasty

Open:

• It is performed under general anesthesia where your surgeon will make a large incision (2 to 3 inches) in the abdomen just below your ribcage.
• The UPJ will be removed, and the ureter will be attached to the kidney pelvis to create a wider opening.
• Drainage tubesare placed at the incision site to drain the remaining fluid. This will promote quick healing.
• The incision will be closed with resorbable sutures (stitches). 
• The procedure takes around 1 to 2 hours.

Laparoscopic:

• This is a minimally invasive procedure that involves using a laparoscope. It is a device with a light source and a camera to project images on a screen. 
• Your surgeon will make multiple keyhole-sized incisions near the abdomen.
• The laparoscope will be inserted from one incision and various surgical instruments, through the other incisions.
• The surgeon will cut the UPJ and reattach the ureter to the renal pelvis for a wide opening.
• The procedure takes around 2 to 3 hours.

Robotic:

• It is a modern technique that uses a surgical robot to perform the procedure.
• The procedure is the same as laparoscopy, but the surgeon performs the surgery with the help of a robotic arm. 
• The surgeon will operate the robotic arm a few feet away from you at a console.
• The surgery takes approximately 3 to 4 hours.

Endopyelotomy

Percutaneous Antegrade Endopyelotomy:

• The procedure is performed under general anesthesia (GA) which involves the use of an endoscope (a thin tube that consists of a light source and camera with a surgical knife attached to it at the tip.
• The endoscope will be inserted through the urethra, via the bladder then into the ureter
• Another insertion method could be percutaneous access (through a small hole in the back region of the kidney).
• The surgical knife is used to cut the part of the obstruction slowly, and the two cut ends will be reattached.
• A temporary internal tube (stent) may be kept for 4 to 6 weeks.

Retrograde Endopyelotomy:

• This procedure is similar to a laparoscopic procedure.
• A urethroscope (an instrument to view the interior of the urethra) will be inserted into the bladder until the renal pelvis.
• The obstructed portion will be removed, and a stent will be placed from the bladder to the renal pelvis.

Acucise Endopyelotomy:

• This procedure is similar to a retrograde endopyelotomy.
• A balloon catheter having a contrast material will be used that has a cutting wire attached to it.
• The catheter is introduced into the pelvis through the bladder.
• The balloon will be inflated with gas once it reaches the ureter.
• The cutting wire removes the obstructed part, and a ureteric stent will be placed.
• All three types of endopyelotomy take around 2 to 3 hours.

New research is underway for laser endopyelotomy (LEP) with high success rates and low risk of complications.

Complications could develop if the ureteropelvic junction obstruction is left untreated and may also arise post-surgery. 

Complications of UPJ Obstruction:

• Recurrent urinary tract infections are most often due to the pooling of urine at the UPJ, which provides a favorable environment for the bacteria to strive and cause infections.
• Chronic loin pain due to increased renal pressure owing to the abnormal pooling of urine around the renal pelvis.
• The formation of secondary renal stones is caused due to the high mineral content in the urine that pools around the UPJ obstruction.
• Partial or complete loss of kidney function due to increased pressure caused by prolonged obstruction.

Complications of Surgical Management of UPJ Obstruction:

• Recurrent ureteropelvic junction obstruction.
• Trauma is caused to the surrounding organs due to the poor surgical skills of the surgeon. 
• Pyelonephritis is an inflammation of the kidneys caused by bacterial infection.
• Excessive bleeding during the procedure.
• Increased urine incontinence (leakage).

Congenital ureteropelvic junction obstruction cannot be prevented since there is no link between the pregnant mother's diet and the formation of the UPJ obstruction. However, adults not born with UPJ obstruction should reduce their risk of developing it later. Hence avoid:

• The formation of kidney stones
  • Reduce salt intake
  • Limit sugar-sweetened foods and drinks like pastries, and juices
  • Cut down on high-purine foods like red meat, and shellfish
• Urinary tract infections
  • Maintain proper personal hygiene
  • Avoid holding your urine for longer periods of time
• Trauma to the kidneys
  • Use safety equipment during high-impact sports and activities
  • Wear seat belts and drive safely

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