Congenital ureteropelvic junction obstruction: A pragmatic approach

Management of the asymptomatic ureteropelvic junction obstruction continues to challenge the pediatric urologist. Decisions as to appropriate and effective imaging, monitoring, and intervention remain unclear due to our inability to accurately define the potential risks of renal injury or clinical symptoms in a particular individual. While it has become well established that many of these children will resolve their apparent partial obstruction without sequelae, knowing who may be at risk remains uncertain. It is important to recognize the limitations in our ability to clinically assess UPJO and the variability of diagnostic testing, but we can develop pragmatic guidelines for care. These are based largely on a cautious approach to obstruction with the recognition that as long as there is a program of monitoring and the family is in agreement with such an approach, watchful waiting can be safe and effective. There are clear parameters to indicate the value of surgery such as reduced relative function, progressive dilation, or increasing washout times or symptoms. It is rare for function to be lost quickly in the older child so intervals of follow-up may be increased with time. Using pragmatic guidelines and a recognition of the limitations of current imaging technology, children with UPJO can be safely and efficiently managed with a largely watch-and-wait approach with operative intervention selectively.