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Urinary and Genital Disorders (Children)

Chronic flank pain following upj repairs

09/08/2010

Question:

My daughter had her first upj repair for obstruction when she was 7 in 1997 (open procedure). She was fine for about a year when the pain returned. Endopyleotomy performed twice to cut away scar tissue thought to be blocking ureter. Also treated with steriod injections at incision site to reduce scar tissue thought to possibly be causeing some nerve discomfort. She has always experienced pain, but has learned to deal with it. Two yrs. ago at 17, the pain had again become unbearable and a upj redo was done laproscopicly. Next year, 2008, still experiencing pain. Surgery performed to free ureter from scar tissure and inervate the kidney. She felt better even though there was still some pain issues. Now the pain has once again increased to the point that she can`t deal with it and the kidney infections have become more frequent. Now on macrodantin profilaticly. Infection has cleared and last mag study shows possible obstruction, but it`s hard to tell because functioning and drainage will never be that great. Have appt. with specialist next week. As you can see she has been dealing with this for almost 13yrs. never being completely pain free. I have read questions from several others who have the same problems with the unexplained pain following this type of surgery. I wanted to see if anyone has been able to determine possible causes of their pain and was anything done to resolve it? Do you think a Whitiker Test would be helpful in her situation?

Answer:

This is a very complex problem. Although most children do well after repair of a UPJ obstruction, some have ongoing pain, sometimes years after the original surgery. Various imaging studies often are performed including diuretic renography (e.g., MAG-3 diuretic renogram), MR urogram, and even a Whitaker test, in which a percutaneous catheter is inserted through the kidney into the renal pelvis, and pressure/flow studies with fluoroscopy are performed. The other problem is that the more surgical procedures that have been performed, the higher the risk of failure or persistent kidney pain. Current data suggest that an endopyelotomy does not have the same success rate as a redo pyeloplasty or a ureterocalicostomy, but often the endopyelotomy is successful. In some cases it is helpful to insert a percutaneous nephrostomy tube to drain the kidney and determine whether the painful episodes disappear. Subsequently, an antegrade x-ray study with contrast (antegrade nephrostogram) can help show whether the ureteropelvic junction is patent or obstructed. Pressure studies (Whitaker test) also can be helpful, but I rarely use this test.

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Response by:

Jack S Elder, MD, FACS, FAAP Jack S Elder, MD, FACS, FAAP
Clinical Professor of Urology
School of Medicine
Case Western Reserve University