What is the gold standard treatment for a patient with moderate right hydronephrosis (kidney swelling) due to pelviureteric junction (PUJ) stenosis, multifocal cortical scarring at the left kidney, and a small left renal cortical cyst?

Management of Pelviureteric Junction Stenosis with Hydronephrosis

The gold standard treatment for moderate right hydronephrosis due to pelviureteric junction stenosis is Anderson-Hynes dismembered pyeloplasty, which can be performed via open, laparoscopic, or robotic approach. 1, 2, 3, 4

Diagnostic Confirmation

Before proceeding with definitive treatment, confirm the diagnosis with:

• CT urography (CTU) - to evaluate the anatomy of the collecting system and rule out other causes of obstruction 5
• Diuretic renography (preferably with MAG3) - to assess the degree of functional obstruction and differential renal function 5

Treatment Options

First-line Treatment

1. Surgical Pyeloplasty

   • Anderson-Hynes dismembered pyeloplasty - involves excision of the stenotic segment, reduction of redundant renal pelvis, and reanastomosis of the ureter to the renal pelvis
   • Success rates exceed 90-95% 2, 3, 4

   Approach options (in order of increasing invasiveness):

   • Robotic-assisted laparoscopic pyeloplasty - combines advantages of minimally invasive approach with improved precision
   • Laparoscopic pyeloplasty - less morbidity, shorter hospital stay (5.9 vs 13.4 days), smaller incision (4.1 vs 23.8 cm), and lower pain scores compared to open surgery 4
   • Open pyeloplasty - traditional approach with excellent outcomes but greater morbidity

Alternative/Temporary Options

1. Percutaneous nephrostomy (PCN)

   • Temporary decompression prior to definitive surgery
   • Indicated when immediate relief of obstruction is needed
   • Can be used as a bridge to definitive treatment 5

2. Endopyelotomy

   • Lower success rates (65-70%) compared to pyeloplasty (>90%) 3
   • May be considered in select cases but not as first-line treatment

Special Considerations

Left Kidney Findings

• The multifocal cortical scarring and relatively small size of the left kidney suggest chronic kidney damage
• The small renal cortical cyst is likely incidental and typically requires no intervention
• These findings should be monitored but don't alter the management of the right-sided PUJ stenosis

Potential Complications

• Urine leak - occurs in approximately 5-10% of cases
• Persistent obstruction - may require revision surgery
• Bleeding - more common with percutaneous approaches
• Infection - can be minimized with appropriate perioperative antibiotics

Follow-up Protocol

1. Ultrasound at 6 weeks, 3 months, and annually thereafter
2. Diuretic renography at 3-6 months post-surgery to confirm resolution of obstruction
3. Monitor serum creatinine to assess overall renal function

Treatment Algorithm

1. Confirm diagnosis with CTU and diuretic renography
2. Assess renal function - if severely impaired, consider temporary PCN decompression
3. Proceed with pyeloplasty - preferably minimally invasive approach if expertise available
4. Post-operative monitoring with ultrasound and diuretic renography

Conclusion

While various approaches exist, dismembered pyeloplasty remains superior to endourological techniques for the treatment of PUJ stenosis, with laparoscopic and robotic approaches offering reduced morbidity compared to open surgery while maintaining equivalent success rates 4.