Pelviureteric Junction Obstruction Associated with Vesico-ureteric reflux and Vesico-ureteric Junction Obstruction: Challenges and Management Protocols

Objective: To assess the incidence and outcome of cases of pelviureteric junction obstruction (PUJO) with associated vesicoureteric reflux (VUR) and/or vesicoureteric junction obstruction (VUJO). Methods: This retrospective analysis included cases of PUJO with associated VUJ anomalies managed between January 2000 and April 2013. All the cases were operated first for PUJO by Anderson-Hynes pyeloplasty via lumbotomy approach. Follow up was done by ultrasound and renal dynamic scan (RDS) at 6 weeks after surgery. Second surgery done was Cohen's ureteric reimplantation after 6 weeks or later. They were subsequently followed by using standard follow up protocol. Results: Out of a total of 29 cases, four cases had an associated VUJO while remaining 25 cases had an associated VUR. VUJO cases presented with poorly functioning kidneys with average split renal function (SRF) of 7%. These cases underwent PCN as an initial management. Follow up RDS were suggestive of VUJO in two cases and were then confirmed with an antegrade dye study. Two cases were found to have VUJO on intraoperative saline test. These cases subsequently underwent Cohen's ureteric reimplantation. Mean SRF in patients with VUR was 22%. Mean number of surgeries per patient was 2. Two cases with consequent VUR didn't show improvement in SRF in last follow up. Rest of the patients showed a significant improvement in SRF after surgery. Conclusion: Concurrent presence of PUJO and VUJ anomalies is a diagnostic challenge. These cases can be managed nicely if a protocol based approach is followed.