MEN'S HEALTH MATTERS:Obstruction in kidney may require surgical intervention
Q I am 25 years old and recently started getting pains in my left loin area. The discomfort is not there at all times, but is certainly made worse if I have a few beers or just drink a lot of fluids. My general practitioner organised a scan of my abdomen and kidneys, which showed that my left kidney was “blown up” and the radiologist mentioned that it could be due to an obstruction to the tube draining my kidney, calling it a PUJ obstruction. My GP has referred me to a urologist. What is this condition and how is it treated?
AWhat you may have is a condition called pelvi-ureteric junction (PUJ) obstruction, but further tests will need to be done to clarify the situation. This condition is due to a narrowing of the junction between the renal pelvis (part of the kidney) and the ureter (tube that links the kidney and bladder).
PUJ obstruction is more common in males and tends to affect the left kidney more often than the right, with less than 5 per cent of people having a significant problem in both kidneys. It is often present from birth, but usually does not become apparent until adolescence or early adult life.
Pain or discomfort in the side or flank is the most common feature and this is often made worse by a high fluid intake, particularly after drinking alcohol. The amount of pain experienced is often dependent upon the degree of blockage.
Blood in the urine or a kidney infection with temperatures are not uncommon presenting features of this condition. Left untreated, PUJ obstruction may cause a number of problems, including diminution of function in the affected kidney over time. It may also be a precipitating cause for the formation of kidney stones.
Assessment of any patient with PUJ obstruction will firstly involve the taking of a full history followed by a physical examination, which may reveal some swelling or tenderness in the flank. Investigations may include an ultrasound or CT scan, which may show an enlargement of the affected kidney as a result of the obstruction.
An intravenous urogram (IVU), which involves using a special dye injected into a vein in your arm, was routinely performed in the past, but is used less often these days. A nuclear medicine scan called a renogram is generally performed to diagnose a PUJ obstruction. This scan or study is a simple outpatient test that involves administering small amounts of radioactive substances, called tracers, into the body and then imaging the kidneys and bladder with a special camera.
The images obtained can help in the diagnosis of PUJ obstruction and will also give an estimation of the function of both kidneys. Some patients with findings on ultrasound scanning such as in your case may not have any obstruction as determined by renogram.
The need for treatment depends on the effect of the obstruction on the kidney, the presence of complications and the severity of your symptoms.
Surgery is reserved for those patients in which the condition is becoming increasingly painful or where the obstruction is causing damage to the kidney with decreasing function. It may also be necessary if the obstruction is causing kidney stones to develop.
Surgery is not always necessary. Many people live with the condition by controlling symptoms with painkillers and antibiotics. Patients not requiring surgery may be managed with careful follow-up.
The most common surgical technique involves removing the obstructed area and joining the ureter back to the kidney, which is called a pyeloplasty. Surgery to relieve the obstruction has success rates of up to 95 per cent. The method of choice is by laparoscopic (keyhole) surgery, using several small incisions, and open surgery is rarely indicated.
Laparoscopic surgery has significant benefits with quicker recovery, reduced pain relief, shorter hospital stays, and the obvious benefit of not having a large surgical incision.
If you need to have an operation, it generally necessitates no more than a couple of days in hospital. A small plastic tube is often left inside to help with the healing process and this is generally removed after six weeks using a small telescope passed through the water passage under local anaesthetic.
Occasionally, the kidney will be found to have very little function and in these circumstances it is best to remove it rather than attempt a repair job. The kidney can be removed using keyhole surgery and rarely open surgery is indicated. It is possible to lead a completely normal life with one normal functioning kidney.
- This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James's Hospital, Dublin, with a contribution from Dr James Forde, urology registrar, St James's Hospital, Dublin
- Please send your questions to healthsupplement@irishtimes.com.
