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Early Sonographic Improvement In Hydronephrposis After Pediatric Pyeloplasty Precludes Need For Long Term Follow Up Imaging
Paul H. Smith, III, MD, David Qi, BS, Jay D. Raman, MD, Ross M. Decter, MD.
Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA, USA.
Hydronephrosis improves gradually after pediatric pyeloplasty, therefore, persistent hydronephrosis on early postoperative renal ultrasound (RUS) is generally not a cause for concern. Early improvement in hydronephrosis is strongly correlated with a non-obstructive pattern on diuretic renography. The intensity and duration of follow up imaging necessary after pyeloplasty remains controversial, but would ideally be tailored to detect those patients at risk for recurrent obstruction and limited in those patients with no risk for recurrent obstruction. We review findings on serial RUS exams following pyeloplasty in an effort to identify early sonographic findings predictive of long-term outcome and to better define the need for serial post-pyeloplasty RUS.
A retrospective medical chart review was performed for pediatric patients who underwent primary unilateral dismembered pyeloplasty between 2001 and 2010 at our institution. Eligible patients had preoperative RUS, early postoperative RUS (1-4 months), and late postoperative RUS (≥12 months). Hydronephrosis was graded as none, mild, moderate, or severe by a pediatric radiologist. Changes in the degree of hydronephrosis and the timing of the changes were compared between patients with successful repair and those requiring an additional surgical intervention for recurrent obstruction.
Of 166 pediatric patients who underwent pyeloplasty between 2001 and 2010, 118 patients met the inclusion criteria. 65% were male and the median age was 57 months at the time of surgery. Median follow up in our cohort was 45 months. Six patients (5%) had persistent or recurrent ureteropelvic junction obstruction. Management included redo pyeloplasty in 5 patients, and nephrectomy in 1 patient. On early postoperative RUS, the degree of hydronephrosis improved in 43 (36%) and was unchanged or worsened in the remaining 75 (64%) patients. None of the patients with early RUS improvement had a clinical failure or required a subsequent procedure. Conversely, all 6 failures occurred in patients with unchanged or worsened hydronephrosis on early RUS.
The ideal duration of follow up imaging after pyeloplasty remains controversial. Fear of late recurrent obstruction often forms the basis for prolonged follow up imaging. None of our patients with improved hydronephrosis on early postoperative RUS developed obstruction, suggesting that prolonged follow up may be unnecessary in such patients.
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