PYELOPLASTY IN INFANTS

With the advent of routine maternal ultrasound ; more and more cases of antenatal  hydronephrosis are being seen in paediatric urology practice.

There was and has been a debate about optimum timing for the management of Pelvi ureteric junction obstruction ; but the consensus is slowly reaching for early pyeloplasty in select few cases for early recovery of differential renal function.

We saw a case of antenatal hydronephrosis ; the baby was followed up after the birth with ultrasound and DTPA renogram.The ultrasound revealed right pelviureteric junction obstruction with moderate  pelvicalyceal dilatation and cortical thinning.

The DTPA renogram revealed  significant stasis and delayed excretion ( 51% differential function:? the function might have been exaggerated because of hydronephrosis and increased area of tracer distribution).

We did routine hematological/biochemical tests.Urine culture revealed Klebsiella pneumoniae.Micturating cystourethrogram was essentially normal.

the decision was made for  right open pyeloplasty.

Usually Anderson Hynes pyeloplasty( dismembered pyeloplasty ) is performed .

As the anesthetic risk is high till 2-3 months years usually a decision is taken to wait till 3 months of the age .After this age the anaesthetic complications are low till the adult age.Waiting beyond 3 months of age can prove to be counterproductive as immature kidney will have to lose its nephrons because of the persistent obstruction.   

The surgery is done with 4 cm incision in lumbar region and the peritoneum is swiped forwards after dissecting the flat muscles of the abdomen.The pelviureteric junction region is accessed.The narrow segment is excised and spatulation of the ureteric side and tailoring of the pelvic side is performed and the anastomosis is made with 5-0 Vicryl sutures ( in the interrupted fashion). 

SPATULATION OF THE URETER ON THE MEDIAL SIDE

PELVIC OPENING BEFORE THE TAILORING 

We usu magnifying loupe for greater accuracy in suturing technique.The surgery takes around 2-3 hours and we stent the anastomosis with the indwelling ureteric DJ stent.A retroperitoneal drain is kept to drain any retroperitoneal fluids.

We feel that with the precise suturing , meticulous dissection and minimal handling of delicate ureteric and pelvic tissues( along with usage of the magnifying loupe ) the complications like anastomotic leak and anastomotic stricture are less.( usually these complications occur in 8-10 % of the cases).