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PUJO in surgery

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PUJO surgery medical term meaning

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Here is a comprehensive overview of PUJO (Pelvi-Ureteric Junction Obstruction) in surgery:

PUJO — Pelvi-Ureteric Junction Obstruction

PUJO stands for Pelvi-Ureteric Junction Obstruction (also written PUJ Obstruction). It is an obstruction to urine flow from the renal pelvis into the ureter at the pelvi-ureteric junction.

Incidence

  • Most common cause of unilateral hydronephrosis
  • Incidence: 1 in 500 live births
  • More common in males and on the left side
  • Bilateral in 10% of cases

Etiology / Causes

  1. Intrinsic obstruction — aperistaltic segment at the PUJ due to muscular hypoplasia (most common)
  2. High insertion of the ureter into the renal pelvis
  3. Crossing aberrant (polar) vessels at the PUJ

Clinical Presentation

Age GroupPresentation
Antenatal / NeonatesDetected on antenatal USS; palpable flank mass
ChildrenIntermittent flank pain, UTI, flank mass
AdultsBack/flank pain, recurrent pyelonephritis
Any ageDietl's crisis — severe flank pain after large fluid intake, relieved by passing large amounts of urine

Investigations

InvestigationFindings
UltrasoundSymmetrical hydronephrosis, dilated renal pelvis, parenchymal thickness, cortical echogenicity
Isotope diuretic renography (DTPA/MAG3)Investigation of choice — renogram curve; T½max >20 min after furosemide = obstruction
CTU / MRUUsed for further anatomical evaluation

Renogram — Obstructive Pattern:

Isotope renogram showing obstructive curve in PUJO with hold-up of contrast up to 2 hours
Criteria for significant obstruction (indication for surgery):
  • Rising renogram curve after furosemide
  • T½max > 20 minutes
  • Differential function < 40% on the affected side

Surgical Treatment

Anderson–Hynes Dismembered Pyeloplasty

The procedure of choice.
Prerequisites of a good pelvi-ureteric anastomosis:
  1. Dependent
  2. Wide
  3. Funnel-shaped
  4. Good vascularity maintained
  5. Without tension
  6. Redundant pelvis excised
Indications for pyeloplasty:
  • Persistent pain
  • Hypertension
  • Haematuria
  • Secondary renal calculi
  • Recurrent UTIs

Steps of Open Dismembered Pyeloplasty:

Steps of Anderson-Hynes dismembered pyeloplasty — PUJ stenosis excision, diamond-shaped incision on pelvis, lateral spatulation of ureter, double J stent placement

Endoscopic Management

  • Endopyelotomy is reserved for post-pyeloplasty strictures (not the primary treatment)

Associations

PUJO is associated with:
  • Horseshoe kidney (increased incidence of PUJO + stone formation)
  • Ureteral duplication
  • Multicystic dysplastic kidney (MCDK) — MCDK is the 2nd most common cause of abdominal mass in newborns after hydronephrosis due to PUJO
— Bailey and Love's Short Practice of Surgery, 28th Edition, Ch. 82
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