title: Functional outcomes of early versus delayed pyeloplasty in prenatally diagnosed pelvi-ureteric junction obstruction.
abstract: Although initial conservative management is popular in the management of antenatally detected pelvi ureteric junction (PUJ) obstruction [1-3], several authors [4,5] have questioned this approach and expressed concern about failure to recover the function lost during expectant management following surgery. In this single center prospective study, we have compared the functional outcomes following early versus delayed pyeloplasty in SFU grade 3-4 PUJ obstruction.
  
  
  METHODS
  Among those children, who presented between 2004 and 2013, with prenatal diagnoses of unilateral PUJ obstruction (n = 886), those with SFU grade 1 or 2 hydronephrosis on USG (n = 533) were excluded. In the remaining 353 children with SFU grade 3 and 4 hydronephrosis, 243 had obstructive pattern on radionuclide scan. After excluding those with severely impaired or supranormal split renal function (SRF), palpable mass, single kidney status, bilateral disease and associated other urological anomalies a total of 126 children were included in the study group. Parents who were unwilling for a frequent follow-up underwent early pyeloplasty, (Group I: n = 62) while the remaining underwent initial conservative management, with 3 monthly USG and nuclear scans (Group II; n = 64). In this group pyeloplasty was performed whenever there was deterioration in SRF >10%, or urine infection or pain during the follow-up. A standard open dismembered pyeloplasty was performed by the same surgeon in all patients. Radionuclide scan was performed at 1 year, at the same center using the same protocol, to assess final SRF and drainage. The functional outcomes were compared using student's t test and chi square test.
  
  
  RESULTS
  Group I comprised of 62 patients while Group II 64 patients. The mean age at pyeloplasty was 2.8 months in group I while 12.5 months in group II. There was no significant difference in the initial antero posterior diameter (APD) between the groups; 30.2 (±3.2) mm in group I and 29.6 (±3.7) mm in group II. At 1-year follow up after surgery, there was improvement in the APD, 16.8 (±4.2) mm in group I and 18.2 (±4.5) mm in group II, with no significant difference between them. In group I, the initial mean SRF was 34.1% (±6.4) and there was significant improvement (p = 0.01) in mean SRF to 37.2 (±7.1) at 1-year follow up after surgery. In group II, the mean SRF was 35.9 (5.7) initially and there was a deterioration to 32.6 (±5.5) before surgery (Figure). At 1-year follow up after surgery, there was a marginal improvement to 33.5 (5.6), however it was significantly lower compared to the initial SRF (p = 0.01). Compared to initial function, at 1-year follow up after pyeloplasty, SRF improved in significantly higher number of patients; 17/62 (27.4%) in group I while only 7/64 (10.9%) in group II (p = 0.03) (Table). There was significantly fewer patients with deterioration in final SRF at 8/62 (12.9%) in group I compared to 22/64 (34.4%) in group II (p = 0.03).
  
  
  CONCLUSIONS
  Although several publications [1-3] have reported functional recovery during initial conservative treatment of PUJ obstruction, in our study a large proportion of patients (80%) in Group II had loss of function during follow-up. This is probably because the study population included only SFU grade 3-4 with obstructive renogram. Several authors have expressed concern about irreversible loss of renal function during expectant management [4,5]. Findings of our study reveal that irrespective of initial SRF, early pyeloplasty in prenatally diagnosed SFU grade 3-4 PUJ obstruction leads to significant improvement of SRF, while delayed pyeloplasty leads to a marginal but, significant loss. This fact should be highlighted to parents so that informed decisions can be made regarding early versus delayed surgery.
authors.affiliation: Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India. Electronic address: drrameshbabu1@gmail.com.
authors.forename: Ramesh
authors.initials: R
authors.lastname: Babu
authors.affiliation: Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India.
authors.forename: Vishek Rajendran
authors.initials: VR
authors.lastname: Rathish
authors.affiliation: Department of Radiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India.
authors.forename: Venkata
authors.initials: V
authors.lastname: Sai
mesh_terms: D015331:Cohort Studies; D003251:Constriction, Pathologic / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006869:Hydronephrosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D007682:Kidney Pelvis / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D049268:Positron-Emission Tomography / Q000379:methods; D011247:Pregnancy; D011296:Prenatal Diagnosis; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D014517:Ureteral Obstruction / Q000150:complications* / Q000000981:diagnostic imaging; D013520:Urologic Surgical Procedures / Q000379:methods
keywords: Hydronephrosis; Pelvi-ureteric junction obstruction; Pyeloplasty; Split renal function