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S EC O N D A R Y P U J

O B S TR U C TIO N

SECO N D ARY PU J
O BSTRU CTIO N
DEFINITION of PUJO
ETIOLOGY of PUJO
ASSESMENT of SECONDARY PUJO
MANAGEMENT OPTIONS

D EFIN ITIO N
Ureteropelvic junction (UPJ) obstruction is
defined as an obstruction of the flow of urine
from renal pelvis to the proximal ureter.

ETIO LO GY
Intrinsic obstruction due to scarring of

ureteral valves.
Ureteral hypoplasia resulting in abnormal
peristalsis through UPJ.
An abnormal or high insertion of ureter
into renal pelvis.
Crossing lower pole renal vessel(s)
Rotation of the kidney and renal
hypomobility causing intermittent
obstruction

ETIO LO GY
SECONDARY UPJ obstruction can be

caused by prior surgical intervention


to treat other disorders (e.g. renal
stone disease) or failed repair of a
primary UPJ obstruction.
This obstructive lesion is usually
secondary to ureteral wall and
periureteral scar formation.

ASSESSM EN T ofSECO N D ARY


PU JO
Success in surgery was defined in a

cohort as adequate drainage on a


diuretic renal scan and direct
visualization of PUJ at
ureterorenoscopy. (Tan et al)
Other criteria of success included

symptomatic resolution (> 80% pain relief)


associated with stable or improved renal
function and improved washout from renal
pelvis (i.e. T < 20 min) on renal scan.

ASSESSM EN T ofSECO N D ARY


PU JO
Failure of treatment may be due to

poor surgical technique, PUJ ischemia


with re-stenosis, anastomotic leak with
urinoma and fibrosis, missed crossing
vessel (18-50% cases), ureteric stent
malfunction and diabetes.
In patients of treatment failure helical
CT scan should be considered to assess
for extrinsic causes , renal calculi and
degree of hydronephrosis.

M AN AG EM EN T O PTIO N S for
SECO N D ARY PU JO
ENDOPYELOTOMY
PYELOPLASTY

(open,laproscopic,robotic)
Complex reconstruction :
uretrocalycostomy
Autotransplastation +/- Boari flap
pelvivesicostomy
Long term ureteric stenting or PCN
Nephrectomy
Observation

Endoscopic M anagem ent


Reduced morbidity with quick post

op recovery.
Retrograde and Antegrade
approaches used.
Retrograde technique include wire
cutting ballon and ureteroscopic
laser pyelotomy with holmium or Nd
YAG laser.
Incision is made in the lateral aspect
of PUJ due to less chance of

Endoscopic M anagem ent..


Percutaneous antegrade

endoyelotomy usually considered in


concomitanat pelvic stones (>2 cm).
Contraindications to endourological
management of secondary PUJO are
long stenosed segment (>2cm),
uncontrolled coagulopathy and
active infection.

Reconstructive options of
prim ary and secondary PU JO

Laparoscopic Re-do Pyeloplasty


Re-do Anderson Hynes dismembered

pyeloplasty preferred in missed


crossing vessel at the time of
primary treatment.
Non-dismembered Foley V-Y plasty is
classically described for high
insertion PUJ.

O pen Pyeloplasty for


secondary PU JO
A dismembered or a flap technique is

generally utilized.
Increased morbidity with large
incision.

Robotic Pyeloplasty
Equivalent success rates to that of

laparoscopic and open pyeloplasty at


97% (Shivraman et al)
Increasing use of robotic is in part
due to easier intracorporeal suturing.

Com plex reconstruction & auto


transplantation
Ureterocalicostomy is indicated in

primary PUJO with intra-renal pelvis,


secondary PUJO, complex anatomy
and obliterated PUJ/ ureter after prior
surgery.
Ileal interposition or
autotransplantation may be
considered where ureteric and renal
pelvis repair is not possible.

Long-term U reteric Stenting


Patient preference , clinical , patient

or surgical factors may require


consideration of long term ureteric
stenting as treatment of secondary
PUJO.
May lead to stent symptoms, stent
blockage, UTI and need for regular
stent change.

N ephrectom y
Patients with poor renal function

(<15% on renography) and ongoing


symptoms.
Patients with good function and
severe symptoms who do not want
reconstructive surgery , which carries
risk of failure and subsequent
interventions.

Follow -up after surgical


m anagem ent ofSecondary
PU JO

Close surveillance in first 12 months

and then a bi-annual or annual


review for at least 3 years. (Dimarco
et al)

CO N CLU SIO N S
Secondary PUJO is uncommon due to

good success rates of primary repair.


Modes of secondary intervention is

determined by individual upper tract


anatomy, concurrent medical
conditions, presence of symptoms,
renal unit function and modality of
primary treatment.

CO N CLU SIO N S
Following endopyelotomy there is

enough evidence to support


secondary laproscopic or open
pyeloplasty .
Robotic assisted laproscopic

pyeloplasty may be useful for


difficult secondary PUJO

Thank
you