Operative versus nonoperative management of ureteropelvic junction obstruction in children

To describe and validate our strategy for treating patients with ureteropelvic junction obstruction operatively or nonoperatively according to ultrasonography and nuclear renal scan findings.

A retrospective analysis of 243 patients from 1999 to 2006 with grade 3-4 hydronephrosis was performed. Depending on the grade of hydronephrosis with parenchymal thinning on ultrasonography and renal function on the nuclear renal scan, patients were treated with immediate pyeloplasty, pyeloplasty after a period of observation, or observation only.

Of 243 patients, 116 were found to have UPJO as determined by a half-life >20 minutes. The mean follow-up was 24.0 months (range 3-69). Immediate pyeloplasty was performed in 32 children, and 84 were treated conservatively. Crossover from observation to surgery occurred in 47 children. In the immediate pyeloplasty group, the mean pre- and postoperative differential function was 30.4% and 38.8%, respectively (P < .0001). In the observation-only group (n = 37), the initial mean renal function was 41.4% and stayed stable throughout the follow-up period, at a mean of 43.2% (P = .2764). In the delayed pyeloplasty group (n = 47), the initial mean renal function was 35.9% and increased to a mean of 41.6% after intervention (P = .0003). The median improvement of hydronephrosis on ultrasonography for those who underwent immediate surgery from before to after the intervention was from grade 4 to grade 3 (P < .0001). For those not undergoing surgery, it improved from grade 4 to grade 2.25 (P = .0026) and for those who underwent delayed surgery, from grade 4 to 3 (P = .0003).

According to our findings, the serial ultrasonography findings and initial renal function on nuclear renal scan are better indicators than the half-life alone for determining whether pyeloplasty is indicated.