Question

A child presented with intermittent episodes of left sided flank pain. Ultrasonography reveals a large hydronephrosis with dilated renal pelvis and cortical thinning with a normal ureter. Kidney differential function was observed to be 19 percent. Which of the following is the best management?

• A. Nephrectomy
• B. Pyeloplasty
• C. External drainage
• D. Endopyelotomy

Hint:

Dilated pelvis with a normal ureter equals PUJ obstruction, and 19 percent function is still worth saving.

Answer 1

The Correct Option is B

Step 1: The picture is hydronephrosis with a dilated renal pelvis and a normal (non-dilated) ureter. Obstruction at the junction where the pelvis meets the ureter, with a normal ureter below it, is the hallmark of pelviureteric junction (PUJ) obstruction.
Step 2: The aim is to relieve the obstruction and save kidney function. The standard, definitive operation for PUJ obstruction is a pyeloplasty (Anderson-Hynes dismembered pyeloplasty), which removes the narrow segment and creates a wide, dependent join between pelvis and ureter.
Step 3: The differential function of 19 percent is reduced but the kidney is not dead. As a rule of thumb a function above roughly 10 to 15 percent is salvageable, so the kidney is worth preserving rather than removing. Pyeloplasty can recover or stabilize function.
Step 4: Why the others are wrong. Nephrectomy is reserved for a poorly functioning kidney, usually with function below about 10 percent, which is not the case here. External drainage (nephrostomy) is only a temporary measure, for example in infection, not the definitive cure. Endopyelotomy has lower success rates in children, especially with a very dilated system and crossing vessels, so it is not the best choice.
Step 5: The best management is pyeloplasty.
Answer: Option B, Pyeloplasty.