Pyelo-ureteral junction obstruction in poorly functioning kidneys: Does conservative management play a role in pediatric patients?

BACKGROUND: Management of Pyelo-ureteral Junction Obstruction (PUJO) in poorly functioning kidneys in pediatric patients is still controversial, particularly regarding the role of conservative treatment.

AIM: To evaluate and present the outcomes of internal diversion and follow-up results of a small series of pediatric patients with UPJO in poorly functioning kidneys.

STUDY DESIGN: Retrospective review of 17 consecutive patients with unilateral PUJO in kidneys with Differential Renal Function (DRF) <20% undergoing temporary internal urinary diversion between 2009 and 2021 at a single tertiary center. DRF was reassessed after 1-3 months of diversion and subsequent management was conservative or surgical (pyeloplasty or nephrectomy) based on surgeon's and family's preferences without randomization.

RESULTS: After a trial of internal urinary diversion, 4/17 patients (23%) showed a DRF increase ≥5% (9%-12%), up to a maximum DRF of 28%, 3 underwent pyeloplasty, while 1 was managed conservatively. The remaining 13 patients showed no differential renal function improvement after diversion, and 7 were managed expectantly while 6 surgically (4 pyeloplasty, 2 nephrectomy). Overall, nine patients (53%) were managed surgically and 8 (47%) expectantly After a median (range) follow-up of 3.1 (0.3-7.9) years, no significant difference was observed between groups regarding symptoms ( p  = 0.205), need for further surgery ( p  = 1.000), and renal function ( p  = 1.000).

DISCUSSION: Although fraught with the limitation of a small sample size, this is the first study reporting on the conservative management of this controversial group of patients.

CONCLUSION: In present pediatric series of pyelo-ureteral Junction obstruction in poorly functioning kidneys with differential renal function <20%, function recovery after a trial of internal urinary diversion was quite exceptional, and no difference was observed in outcome between patients managed surgically and conservatively after stent removal.