Upper urinary tract: when is obstruction obstruction?

Obstruction can either be defined as a condition that hampers optimal renal development, or, more conservatively, as a restriction to urinary outflow that, when left untreated, will cause progressive renal deterioration. Currently, management is mostly based on the latter definition, but still remains controversial. Relevant work published before 2002 is considered because of a lack of recent literature.

Almost all reports comparing the primary conservative treatment of suspected obstruction versus early surgical intervention show comparable results, but there are different interpretations. The approach of 'watch and wait' for a unilateral hydronephrotic kidney with normal function is usually quite safe, with a very low risk of the permanent loss of renal function when accompanied by close monitoring, but it is certainly not without risk. At this time, the main underlying problems are that all currently applied diagnostic methods only detect effects secondary to obstruction, and the currently used definition of obstruction is based on a longitudinal observation period. The most relevant publication in the observation period was an in-depth report on a workshop in which the need for valid prospective markers for renal maldevelopment and 'significant' obstruction was expressed.

The optimal management of infants with congenital hydronephrosis and suspected obstruction will remain controversial until new diagnostic methods are able to discriminate between 'harmful' and 'harmless' obstruction. Most experts currently advocate primary conservative management, with close follow-up and surgical intervention only if there are signs of reduced function of the obstructed kidney.