Ureteropelvic Junction (UPJ) Obstruction

Ureteropelvic Junction Obstruction, or UPJ obstruction, is a relatively common problem seen in children. It is a problem with the connection of the ureter, the muscular tube that connects the kidney to the bladder, and the renal pelvis, the main collection chamber for urine in the kidney. In children, this junction can be dysfunctional due to either an actual obstruction or a short segment of ureter that does not push urine forward effectively. These children are usually discovered during pre-natal ultrasound with the finding of a dilated kidney. Pediatric Urologists will then decide if observation of the problem or surgery is indicated.

In adults, the same thing can occur but simply not show itself until adulthood. However, the other cause for a UPJ obstruction seen in nearly 50% of cases in adults is an obstruction of the ureter caused by an extra blood vessel, usually an artery that supplies the lower part of the kidney. As a person gets older, this vessel gets bigger. Since this blood vessel will usually lie over the ureter, it can cause obstruction. This is called a "crossing vessel". Adult patients with an UPJ obstruction will commonly present to medical attention due to the development of kidney stones on the affected side, infections or blood in the urine. Rarely, the patient will describe back pain whenever he/she drinks a lot of fluid. This is called "Dietl's crisis".

When UPJ obstruction is discovered in an adult, the first step is usually to obtain a special radiologic test called a renal scan. This test will tell us if indeed the kidney is obstructed, how obstructed it is, and whether the kidney has suffered any damage from being obstructed for a long period of time. Sometimes, the kidney will be so damaged that we will determine that it is not worth saving. If the kidney is relatively healthy, the next step is to determine the best way to do that.

Historically, perhaps 10 years ago, the Urologist would standardly perform an open operation called a "pyeloplasty" to correct the problem. Here, an approximate 8-10 inch incision would be placed in the flank or side, the obstructed UPJ identified, the obstruction removed, and the healthy ureter reattached to the renal pelvis. Many urologists still perform this operation today.

The first attempts at trying to correct a UPJ obstruction without a large incision were made by putting a tube through the kidney, driving a camera into the renal pelvis, and cutting the UPJ with a small knife and allowing it to heal over a large tube or stent. Later, this same operation was performed through the bladder, up the ureter, in a retrograde fashion. These operations were called either antegrade or retrograde endopyelotomy, and they were very popular for around five years. However, it was found that the long term success rate for these operations was only around 50%. Also, it is more difficult to repair a UPJ obstruction after a failed endopyelotomy. Another approach with a higher success rate was required. What emerged was the laparoscopic pyeloplasty.

The laparoscopic pyeloplasty is the same operation as an open pyeloplasty, with the same long-term success rate of over 93%, performed through tiny incisions instead of one large one. The result is an operation exactly like the open one with a very short recovery time. Patients are usually in the hospital only 1-2 days, and are back to work in 1-2 weeks. Today, these operations have become standard and have practically replaced the open approach in areas where a Urologist with a very advanced level of laparoscopic expertise is available.

At USW, Drs. Engel and Frazier are both very experienced at performing this operation laparoscopically. We also perform portions of the procedure with robotic assistance, thus allowing us to be more precise and delicate when performing the suturing and more complex steps of the operation. Robotic assistance is not crucial for this operation, but we feel that it improves our ability to ensure a water-tight repair and more elaborate dissection, thus leading to a more exact operation.

If you have been diagnosed with an obstructed kidney, perhaps due to an UPJ obstruction, please call to arrange a consultation with us.

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