Case 2 7 year old girl Hydronephrosis diagnosed at the age of 4, regular follow up at Dr.邱’s OPD The initial presentation was abdominal pain and nausea/vomting. Prenatal ultrasound: no significant finding At 2014 Renal echo Right moderate hydronephrosis, with the Antero-posterior diameter of renal pelvis around 3.34 cm No hydroureter was noted At 2015 Right mild hydronephrosis, with the A-P diameter around 0.83cm, SFU grading 1

Case 2 At 2016 Abdominal pain and vomiting condition got gradually severe Renal echo Right severe hydronephrosis, SFU grading IV No hydroureter Suspect UPJ-obstruction Admission for workup

Case 2 8/31 Right PCN insertion Right 24hr urine Ccr: 44(from PCN) Left 24 hr urine Ccr: 74(self-voiding)

Hospitalization course VCUG, 9/5 1. Right vesicoureteric reflux grade, at least III. 2. Suspect right simple ureterocele. 3. Suspicious right sided UPJ stenosis, S/P PCN inserted.

Hospitalization course CRFT diuretic renogram: obstruction in the right collecting system with relatively low renal function (left and right renal function is 72.4% and 27.6%) No obstruction in the left collecting system

Hospitalization course Anterograde pyelogram Right UPJ stenosis with hydronephrosis. High-grade obstruction with only scanty of contrast meidum flow downward

Case 2 Diagnosis Scheduled for operation today VU reflux combined with UPJ obstruction 10% of patients with severe vesicoureteral reflux, UPJ obstruction exists (or develops). Secondary scarring in the presence of highgrade vesicoureteral reflux UTI, s/p Antibiotics treatment Scheduled for operation today

Vesicoureteral reflux Primary(Most common): Due to incompetent or inadequate closure of the ureterovesical junction (UVJ) Secondary: abnormally high pressure in the bladder(posterior urethral valves) posterior urethral valves(Neurogenic bladder)

Vesicoureteral reflux Clinical presentation Prenatally found Postnatal UTI episode Diagnosis: VCUG Management In the majority of cases with primary VUR, especially those with low-grade reflux, there is spontaneous resolution Conservative treatment in mild VUR patients

Vesicoureteral reflux Surgical correction is considered and discussed with the family for children with the following conditions. Grade IV/V reflux in children older than two or three years of age with persistent high-grade reflux or who have breakthrough infection. Children who fail medical therapy and have breakthrough infections, who have significant side effects from continuous prophylactic antibiotic coverage, or whose families are not compliant with a long-term medical regimen. Complications Recurrent UTI episode Renal scarring

Case 1 Case Diagnosis UPJ obstruction VU reflux with UPJ obstruction Cause Congenital Maybe acquired form(renal scarring) Age of diagnosis Prenatally found 4y/o Initial presentation No symptoms yet Abdominal pain nausea/vomiting Renal echo Severe hydronephrosis, grade 4 Severe hydronephrosis, Grade 4 VCUG No VUR At least grade III VUR CRFT(comprehensive renal function test) Obstruction in the left collecting system Obstruction in the right collecting system Anterograde pyelogram UPG obstruction

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