PUJo

Question 1

35y/0 male with Right HUN
What is the differential?

Answer 1

Obstructive vs Non obstructive HUN ( VUR)
Obstructive :
- PUJ - Primary / Secondary
- Ureteric stone
- Blood clot
- Sloughed papilla
- Ureteric stricture ( TB/ Schistosomiasis/Trauma/ iatrogenic)
-Retrocaval ureter
- External compression from Lymphnodes
- RPF
-Pelvic lipomatosis

Bladder - Ureterocoele
NGB with VUR
Urethral obstruction

Question 2

35 y/o male with episode of Macro HU and Right Hydronephrosis on ultrasound
What would you like to do next

Answer 2

NB! Vitals - BP , Temp/ Tacchy
1. Urine dipstick
2. UMC&S
3. FBC, U&E
4. Cystoscopy + RPGs
5. CT 3 phase if normal Crt or CT IVP
6. If PUJo confirmed - Book MAG3 renogram
7. Rx book for Open dismembered pyeloplasty

Question 3

Where does a crossing vessel run in PUJo
Where does the ureter lie in relation to the artery

Answer 3

Abberent vessel Posterior to the PUJ
Vein—> Artery—> ureter—> Artery ( if posterior)

Question 4

Different Pyeloplasty techniques

Answer 4

Open/ Laparoscopic / robotic
1. Dismembered Anderson Heyens Pyeloplasty
2. Foley Y- V pyeloplasty ( HIgh insertion of ureter)
3. Pelvic flap pyeloplasty = Culp de weerd spiral flap
4. Intubated ureterotomy ( Davis) = rare
5. Vascular Hitch

Endoscopic
- Endopyelotomy

Question 5

Describe a Anderson Hynes Pyeloplasty

Answer 5

1. Do a RPG - if not yet done
2. Place a catheter
3. Turn pt in lateral decubitus position - Flank approach
4. Incision from the 12th rib anteriorly 3-4 cm
5. Dissect through the External oblique, int oblique and transverse abdominits
6. Spare the intercostal and subcostal nerves
7. Enter at the 12th rib , bluntly develop the retroperitoneum
   8.Identify Psoas
8. Open Gerotas fascia
9. Expose the PUJ and place stau sutures on the PUJo and the renal pelvis
10. Diamond shape incision marked and made with Pott scissors ( stay awau fromt he calyces)
11. mark the ureter to maintain orientation and avoid twisting
12. Spatulate the ureter along the lateral segment
13. Anastomosis - 4/ 5-0 Vicryl with knot outside
14. JJ stent placed

Question 6

Goal of anastomosis

Answer 6

Widely spatulated
Water tight
Tenseion free
Funnel shaped transition between ureter and pelvis at position of dependent drainage

Question 7

How can you know that the JJ stent is in ?

Answer 7

1. Place blue dye in the bladder if it reflux op the stent , the stent is in the bladder or
2. Flexiscope or
3. C- arm x- rays

Question 8

How do you do an endopyelotomy

Answer 8

1. Ureteroscopy ( Semirigid /FURS)
   2 RPG + guidewire = if narrow place JJ stent 5-10 days
2. 200um holmium fibre ( 0.8-1.2 J ; 10-15Hz)
3. Full thickness lateral incision through the obstructing proximal ureter
4. Incision from the ureteral lumen to periureteral fat
5. Can also do a Balloon dilatation - stent placed

Success rate 79-83%

Question 9

What fascia do you cut through for a pyeloplasty

Answer 9

Lumbodorsal fascia

Question 10

If you would cut posterior to the 12th rib what muscles will you encounter

Answer 10

Sacrospinalis
QUadratus lumborum
Psoas

Question 11

What is the lumbodorsal fasciaa

Answer 11

Describe the lumbodorsal fascia
- surrounds sacrospinalis & quadratus lumborum muscles, making posterior abdominal wall - originates from spinous processes of lumbar vertebrae & extends anteriorly and cranially - separates into 3 layers:
1) posterior - posterior covering of sacrospinalis & origin of latissimus dorsi 2) middle - b/w sacrospinalis posteriorly & quadratus lumborum anteriorly 3) anterior - anterior covering of quadratus lumborum and forms posterior margin of
retroperitoneum
- 3 layers connect laterally with transversus abdominis muscle

Question 12

What is a Dorsal Lumbotomy incision

Answer 12

What is the significance of the dorsal lumbotomy incision?
- vertical incision lateral to border of sacrospinalis & quadratus lumborum } Petit’s triangle  sacrospinalis is middle layer
- allows entrance to retroperitoneum without violation of musculature } no muscles are cut

Patient lies prone and is ideal for bilateralal PUJ repairs

Question 13

What type of renogram would you like and why?

Answer 13

MAG 3 diuresis renogram
- Asess differential function
- Asess Obstruction

Question 14

What are the limits of the Pleura

Answer 14

Ant = 8th rib
MAL = 10 th rib
Post = 12th rib

Question 15

What is a well tempered renogram ?

Answer 15

“A well-tempered renogram is a standardised diuretic renogram used to differentiate obstructed from non-obstructed urinary tract dilatation.
It is performed after 4–6 weeks of age due to immature neonatal renal function.
The study requires adequate hydration, bladder catheterisation, and Tc-99m MAG3 as the radiotracer.
Furosemide is administered at 1 mg/kg, most commonly using the F+20 protocol, which is preferred in children. Interpretation is multiparametric and includes drainage half-time, curve pattern, differential renal function, cortical transit time, normalized residual activity, and gravity-assisted drainage.
A T½ of less than 10 minutes indicates unobstructed drainage, whereas a T½ greater than 20 minutes suggests obstruction. Delayed cortical transit time beyond 5 minutes, NORA values greater than 1, and persistent tracer retention despite gravity-assisted drainage are strong indicators of clinically significant obstruction. Results must always be correlated with ultrasound findings and clinical progression.”

Question 16

What is a Whitacker test?

Answer 16

Whitaker test is done to differentiate obstructed vs non obstructed hydronephrosis
1. Needle in the collecting system/ Nephrostomy
2. Connect to mannometer
3. Infuse contrast at 10ml/min ( 600ml.hr)or blue dye
4. Place a urodynamic TUC to measure the intravesicle pressure
5. The moment contrast reaches the bladder or blue dye is seen, measure the difference between the collecting system - intravesicle pressure
6. Normal < 15cmH20
Intermediate 15-22cmH20
Obstruction > 22cmH20

Question 17

What Protocols do you know for a renogram

Answer 17

Traditionally F+20 = Furosemide at 20
F-15 = 15 min before
F +0 at time

Question 18

Study on Reduction vs non reduction pyeloplasty

Answer 18

1. Non reduction vs reduction pyeloplasty = Meta Analysis
2. No statistical significant differance in postop Diff renal function or change in DRF, or functionnal outcomes, no change in comp risk.
   BJUI, Michelangelo S Cobangbang , 2025

Question 19

What is the indication for surgery for PUJ obstruction

Answer 19

DRF < 40% on 1st test
DRF falls > 10%
Obstructed trace
If APD > 35mm or worsening
Break trhough infections
Sx - pain/ FTT/ feeding difficulties/ HU/ Stones/ HPt

Question 20

Surgical choice and AP diameter

Answer 20

AP> 50mm =100% surgery
AP> 40mm =80% surgery
AP> 30mm = 55% surgery
AP>20mm = 20 % surgery
AP<20mm = in 1-3 % surgery

Question 21

Describe the curves seen in a renogram and the name

Answer 21

O Rilley curve