THE NATURAL-HISTORY OF PELVI-URETERAL JUNCTION OBSTRUCTION IN CHILDREN PRESENTING CLINICALLY WITH THE COMPLAINT

Objective To determine the natural history of untreated pelvi-ureteric junction (PUJ) obstruction in children presenting clinically with the complaint. Patients and methods The study comprised 42 children with anatomical PUJ obstruction (three with bilateral lesions) who were man aged expectantly in the first instance, who had no immediately trouble some symptoms and differential function in the affected kidney(s) of > 40%. They were followed by serial ultrasonography and dynamic diuresis renography. Pyeloplasty was advised for those with persistent symptom s or where differential renal function fell below 40%. Results Only 15 children had presented with clearly relevant symptoms (loin pain or f ebrile urinary infection). Thirty-four kidneys showed obstructive reno graphic curves initially and 38 had moderate or severe hydronephrosis. During the follow-up (range 14-120 months, mean 56) patients remained asymptomatic except for four of the nine presenting with loin pain. R enographic curves were apt to change, with 'obstruction' increasing or decreasing with time, in the latter instance usually with lessening o r resolution of hydronephrosis. Eleven patients underwent pyeloplasty, five for symptoms and six because of deteriorating renal function. Re nal function did not decline in any patient with mild hydronephrosis a nd/or a non-obstructive renographic curve at presentation, but did so disproportionately in those with severe hydronephrosis or a Type TV re nographic curve. Conclusions Patients effectively asymptomatic at pres entation are likely to remain so. Expectant management is appropriate for patients with mild hydronephrosis and/or non-obstructive renograph ic curves at the outset. Conversely, pyeloplasty may be advisable for those with severe hydronephrosis or Type TV renographic curves. Otherw ise, for most the natural history of the complaint remains to be deter mined.