Treatment of Pelvicaliectasis
The treatment of pelvicaliectasis requires a combined medical and urological approach, with nephrostomy and instillation of amphotericin B being recommended for cases involving the pelvicalyceal system when standard systemic antifungal therapy is insufficient. 1
Understanding Pelvicaliectasis
Pelvicaliectasis refers to dilation of the renal pelvis and calyces, which can occur due to various causes:
- Obstruction (stones, tumors, strictures)
- Vesicoureteral reflux
- Pregnancy-related physiological changes
- Infection
- Congenital anomalies
Diagnostic Approach
Before initiating treatment, proper assessment is essential:
- Ultrasonography is the first-line imaging modality to confirm pelvicaliectasis and measure its severity
- In children, measuring the width of a ureteral stone can help predict spontaneous passage 2
- Additional imaging (CT scan, MRI) may be needed to determine the underlying cause
Treatment Algorithm
1. Physiological Pelvicaliectasis
- Common during pregnancy and typically resolves postpartum 3
- Monitor with serial ultrasounds
- No specific intervention required unless complications develop
2. Obstructive Pelvicaliectasis
A. Stone-related obstruction
- For stones <4 mm in children: Observation with hydration as 88.9% pass spontaneously 2
- For stones 4-5 mm: Consider trial of medical expulsive therapy
- For stones >5 mm: Surgical intervention likely required as 66.7% need intervention 2
B. Ureteropelvic Junction Obstruction (UPJO)
- Common in ectopic pelvic kidneys (22-37% of cases) 4
- Surgical correction (pyeloplasty) is the definitive treatment
- Open pyeloplasty has shown 82.6% success rate in pediatric patients with ectopic pelvic kidneys 5
3. Infection-related Pelvicaliectasis
A. Fungal infections (e.g., Aspergillus)
- Combined medical and urological management is recommended
- Nephrostomy to reduce complications of ureteral obstruction
- Amphotericin B lavage of the pelvicalyceal system
- Systemic antifungal therapy 1
B. Bacterial infections
- Appropriate antibiotics based on culture sensitivity
- Consider drainage if significant obstruction present
Special Considerations
Pelvic Kidney with Pelvicaliectasis
- Higher risk of calculi and hydronephrosis compared to normally positioned kidneys 4
- Treatment approaches must account for aberrant vessels and overlying structures
- Laparoscopy-guided intervention may be preferred for percutaneous procedures 4
Pediatric Patients
- Persistent pelvicaliectasis after pyeloplasty in ectopic kidneys may be due to anatomy-related factors 5
- Regular follow-up is warranted in this population
- Preoperative differential renal function and surgeon experience significantly predict improvement after pyeloplasty 5
Congenital Causes
- In cases like imperforate hymen causing hydrometrocolpos with secondary pelvicaliectasis, treating the primary cause (hymenotomy) can resolve the pelvicaliectasis 6
Monitoring and Follow-up
- Serial ultrasound examinations to assess resolution
- Renal function tests to monitor kidney function
- Follow-up imaging based on underlying etiology and severity
Treatment Pitfalls to Avoid
- Failing to identify the underlying cause before initiating treatment
- Overlooking physiological pelvicaliectasis during pregnancy
- Delaying intervention in cases with significant obstruction or infection
- Not considering anatomical variations when planning interventions, especially in ectopic kidneys
- Inadequate follow-up after treatment, particularly in pediatric patients with anatomical abnormalities
The management of pelvicaliectasis should be directed at the underlying cause while preserving renal function and preventing complications such as permanent kidney damage, infection, or stone formation.