PUJS is an alteration in the transport of urine from the pyelon to the ureter, resulting in dilation of the pyelocaliceal cavities, which, if left untreated, leads to a risk of progressive impairment of the function of the affected kidney
[1]
.
The PUJS is the most common congenital uropathy of the upper urinary tract
[2]
.
Its annual incidence is estimated at 5 per 100,000 births
[3]
.
The condition is very often diagnosed and treated prenatally in developed countries, whereas in developing countries it is diagnosed postnatally or even in adulthood
[4]
.
The standard treatment for ureteropelvic junction syndrome is still based on the principles of resection-anastomosis, as set out by KUSS, ANDERSSON, and HYNES
[5]
.
In Mali, this condition is not well known by medical staff, with little statistical data on its diagnosis and management.
We have initiated work to study the epidemiological, clinical, and therapeutic aspects of this condition in our department.
2. Patients and Methods
This was a descriptive cross-sectional study, with retrospective data collection between April 24, 2016, and March 20, 2020 (i.e., 4 years); and prospective data between March 26 and October 1, 2022. We conducted this study over a period of 8 years and 6 months in our urology department at the Pr Bocar Sidy Sall University Hospital in Kati.
We included in our study all patients hospitalized and operated on in the department during the study periods for pyeloureteral junction syndrome.
We did not include any patients admitted to the department for any reason other than pyeloureteral junction syndrome, patients with unusable records for this anomaly, or patients who underwent surgery for pyeloureteral junction syndrome.
After a thorough physical examination, we requested certain additional tests for all patients, such as creatinine, urine culture + antibiogram, renal ultrasound, and uro-CT scan.
All patients underwent open surgery.
The parameters studied were: frequency, age, sex, reason for consultation, clinical and paraclinical signs, imaging, treatment, and postoperative outcomes.
The data were entered into Word 2016 and analyzed using SPSS version 21.0 after verification.
3. Results
During the study period, we collected 30 cases of pyeloureteral junction syndrome out of 897 urological pathologies, representing a hospital frequency of 3.3% and ranking fifth among pathologies (
Table 1
).
<xref ref-type="bibr" rid="scirp.145434-"></xref>Table 1. Distribution of surgical procedures in the Urology Department according to pathology.
PUJS accounted for 3.3% of the department’s surgical activities.
The average age was 23.3 years, ranging from 8 to 53 years. The most represented age group was 20 - 29, with a frequency of 33.3%.
Males accounted for 63.3% of cases, representing a ratio of 1.72.
The reason for consultation was lower back pain in 96.7% of cases in our study.
The left side was most commonly affected in 56.7% of cases, followed by the right side in 26.7% of cases (
Table 2
).
<xref ref-type="bibr" rid="scirp.145434-"></xref>Table 2. Distribution according to the side affected.
Side affected
Number
Frequency (%)
Left
17
56.7
Right
8
26.7
Both sides
5
16.7
Total
30
100.0
Kidney function was impaired in 23.3% of our patients.
The urine culture was positive in 20 patients, or 66.7%. E. coli was the germ found in 65% of cases, followed by K. pneumoniae in 20% of urinary tract infections (
Table 3
).
<xref ref-type="bibr" rid="scirp.145434-"></xref>Table 3. Distribution according to the presence of urinary tract infection.
Identified bacteria
Number
Percentage %
Escherichia coli
13
65
Klebsiella pneumoniae
4
20
Staphylococcus aureus
2
10
Proteus mirabilis
1
5
Total
20
100.0
Uro-CT scans showed thinning of the renal parenchyma in 33.3% of cases and laminated kidneys in 10% of cases.
We performed anastomotic pyeloplasty in 18 patients, or 60% of cases.
The average length of hospital stay was 5 days, ranging from 4 to 10 days.
4. Comments and Discussion
During our study, we collected 30 cases of pyeloureteral junction syndrome in the department, representing 3.3% of patients. This result differs from those of other authors in Mali, who found 21, 35, and 59 cases, respectively, in their studies
[6]
[7]
. This frequency compared to other pathologies can be explained by the fact that pyeloureteral junction syndrome is a congenital pathology that is little known in our country.
The average age of our patients was 23.3 years, with extremes of 8 and 53 years. This result is lower than those of Coulibaly MT and Tembely A et al.
[6]
[7]
in Mali, who found an average age of 26 and 29.3 years, respectively. However, it is higher than those of other authors, who found an average age of 3.8 ± 4.39 years and 4.9 years in their study
[8]
[9]
. This difference in age can be explained by the fact that the latter studies were conducted in strictly pediatric settings.
Males were in the majority in our study, with a ratio of 1.72. A male predominance has also been reported in the literature
[6]
-
[10]
. These results differ from those of Jalloh M et al.
[11]
in Senegal, who found an equal ratio of 1, i.e., 4M/4F.
Lower back pain was the reason for consultation in 96.7% of our patients. Jalloh M et al.
[11]
also found pain to be the reason for consultation in all their patients. In the literature, other authors have found painful symptoms in some of their patients, namely 40% and 35.6% in
[7]
[9]
respectively. This high frequency can be explained by the absence of antenatal findings but also by delays in consultation. The clinical manifestations of pyeloureteral junction syndrome are very varied. They depend on the type of pyeloureteral junction, the degree of obstruction, and the age of the subject.
In our study, the left kidney was most often affected, with a frequency of 56.7%. Jardak et al.
[12]
found the same results in 56.52% of their patients. This is similar to the findings of Zarfati A
[13]
and Sidibé S
[14]
, a frequency of 59% and 66.7% respectively in their study. The right side was predominant in Jalloh M et al. (11) in 75% of cases.
In our study, 27% of patients had urinary disorders (pyuria and hematuria). Our results differ from those of Coulibaly D in Mali, who found a pyuria rate of 25% in their study
[15]
.
Temporary kidney failure was found in 23.3% of cases. This result is similar to those of KPATCHA T.M. et al.
[16]
, who found kidney failure in 20% of cases, while Galifer R. B et al. in France
[9]
found a frequency of 3.7% of temporary kidney failure. In the study by Tembely A et al., impaired renal function affected 34.3% of patients. Our high frequency can be explained by the delay in consultation by our patients.
In our study, urine culture was positive in 66.7% of cases, and E. coli was the germ found in 65%. Our results are higher than those of Amadou I et al. in Mali, who found urinary tract infection in only 28.6% of their study
[8]
.
Lumbotomy was the main approach in our study. Conservative surgery with Kuss Anderson pyeloplasty was performed in 60% of our patients. This result is comparable to that of Tembely A et al. in Mali
[7]
, who performed pyeloplasty on 51.1% of patients.
Nephrectomy was performed in 40% of our patients, a result that is far superior to that of Galifer R B et al. in France
[9]
, who obtained a frequency of 5.9%. Kpatcha et al. performed the Kuss Anderson technique in 68% of cases, with 8% undergoing nephrectomy. This high frequency of nephrectomy in our patients is justified by the destruction of the renal parenchyma due to the delay in consultation by our patients. This high rate of nephrectomy in our series is mainly due to a lack of awareness of the disease among the general population and general practitioners. The latter (general practitioners) begin to treat patients medically over a long period of time without referring them to urologists in a timely manner. Only the diagnostic and therapeutic management of this disease can prevent the destruction of the renal parenchyma in our countries.
The average length of hospital stay was 5 days, ranging from 4 to 14 days. DANJOU P et al.
[17]
found an average length of stay of 3 days in their study. Delays in discharge from hospital were due in most cases to parietal suppuration. This significant difference can be explained by the fact that all our patients underwent lumbotomy, while those in the study by DANJON P et al.
[17]
underwent laparoscopic surgery.
We noted pain relief and improved renal function and pyelocaliceal cavity morphology in all cases where conservative surgery was performed (60%).
The limitations of our study were the small sample size, the fact that it was a single-center study, and that all our patients underwent open surgery.
5. Conclusions
PUJS remains the most common obstructive uropathy in our department, and diagnosis is still made radiologically.
Abdominal-pelvic ultrasound plays an important role in guiding diagnosis, showing hydronephrosis in every case, but CT URO is the gold standard for confirming diagnosis in our countries.
Open surgery still has its place in our countries, despite advances in minimally invasive surgery (laparoscopic surgery). This surgery can preserve or restore renal function when the diagnosis is made early, although this often comes at the cost of parietal complications (parietal suppuration).
The development of imaging techniques in our countries can enable early diagnosis and guide the management of pyeloureteral junction syndrome.
The management of pyeloureteral junction syndrome has changed completely in recent years with the development of minimally invasive urological surgery techniques (endourology and conventional and robot-assisted laparoscopic surgery). The implementation of these techniques and the training of urologists in our developing countries allow patients to be treated under optimal conditions, with reduced morbidity and shorter hospital stays.
References
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