ARTICLE

Intermittent Hydronephrosis Secondary to

Ureteropelvic Junction Obstruction: Clinical and
Imaging Features
Jeng-Daw Tsai, MDa,b, Fu-Yuan Huang, MDa,b, Chun-Chen Lin, MDa, Tsuen-Chiuan Tsai, MDa, Hung-Chang Lee, MDa,b, Jin-Cherng Sheu, MDc,
Pei-Yeh Chang, MDd
Departments of aPediatrics and cPediatric Surgery, Mackay Memorial Hospital, Taipei, Taiwan; bDepartment of Pediatrics, Taipei Medical University, Taipei, Taiwan;
dDepartment of Pediatric Surgery, Chang Gung Childrens Hospital, Taoyuan, Taiwan
The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. We sought to assess the clinical and imaging findings in intermittent
hydronephrosis secondary to ureteropelvic junction obstruction, with particular
emphasis on the characteristic ultrasonographic findings.
METHODS. This prospective, longitudinal, observational study included all children
who had intermittent ureteropelvic junction obstruction and presented with abdominal pain over 6 years. Renal ultrasound was used as an initial screening tool
to detect intermittent hydronephrosis. Renal ultrasonography was repeated every
1 to 2 days to record serial changes from the symptomatic to the asymptomatic
stage. Their clinical manifestations and imaging findings were studied.
RESULTS. Eighteen patients (14 boys, 4 girls) were studied. Most had sharp pain that

began acutely and typically lasted for 2 days. Most of the children (16 of 18) had
nausea and vomiting that accompanied the pain. The acute episode generally
resolved spontaneously and was followed by a pain-free interval that ranged from
days to months. Factors that predisposed to an attack included increased water
intake, vigorous exercise, or bladder distention. All patients had clearly demonstrable obstruction of the renal pelvis during an acute attack, a finding that
diminished or resolved during the symptom-free intervals. During convalescence,
all patients had renal pelvic wall thickening on ultrasonography. This finding
appeared on the second or third day after a painful episode subsided, persisted for
6 to 9 days, and then disappeared in the symptom-free stage. Pyeloplasty was
performed in 17 patients, none of whom had recurrent pain on follow-up. Extrinsic obstructions were found in 9 patients.

www.pediatrics.org/cgi/doi/10.1542/
peds.2005-0583
doi:10.1542/peds.2005-0583
Key Words
intermittent hydronephrosis,
ureteropelvic junction obstruction,
prospective studies, renal
ultrasonography, renal pelvic wall
thickening, convalescence, intravenous
pyelogram, diuretic renal scan,
computed tomography, dismembered
pyeloplasty, follow-up
Abbreviations
UPJO ureteropelvic junction
obstruction
IVPintravenous pyelogram
VCUGvoiding cystourethrography,
CT computed tomography
DTPA diethylene triamine
pentaacetic acid
Accepted for publication Jun 20, 2005
Address correspondence to Pei-Yeh Chang,
MD, Department of Pediatric Surgery, Chang
Gung Childrens Hospital, 5-7, Fu-Hsin St,
Kwei-Shan, Taoyuan, Taiwan. E-mail:
pyjchang@cgmh.org.tw
PEDIATRICS (ISSN 0031 4005). Copyright 2006
by the American Academy of Pediatrics

CONCLUSIONS. The keys to diagnosis are awareness of the syndrome, a detailed

history, and immediate and serial imaging studies during painful crises. A thickened renal pelvic wall during convalescence is an important ultrasonic sign of
intermittent hydronephrosis.

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139

RETEROPELVIC JUNCTION OBSTRUCTION (UPJO) is attributed to a functional or anatomic narrowing of

the junction between the renal pelvis and the ureter. It
is 1 of the most enigmatic clinical problems today. The
obstruction may remain stable, diminish over time,
progress, or occur intermittently. Intermittent UPJO is
usually acute but self-limited. It causes a distinct clinical
syndrome of severe episodic abdominal pain, nausea,
and vomiting associated with intermittent hydronephrosis known as Dietls crisis.1 It was first described by Dietl
in 1864. Rapid distention of the pelvis and stretching of
the renal capsule explain the acute pain.2 It is not unusual for these patients to have a long-standing history
of episodic abdominal pain that is not diagnosed correctly.25
In 1956, Nesbit6 was the first to point out that the
intravenous pyelogram (IVP) in patients with intermittent hydronephrosis may be normal between acute episodes. Unless patients are investigated during the brief
episode of pain, the obstruction is easily missed, and the
pelvicaliceal system may appear normal or only minimally dilated during pain-free intervals. Imaging during
an attack or on provocative testing, eg, diuretic IVP,
diuretic ultrasonography, or diuretic renal scan, is
needed for correct diagnosis.7 The purpose of this study
is to present our experience in the diagnosis of intermittent hydronephrosis, with particular emphasis on the
characteristic clinical and imaging findings in intermittent UPJO. We present serial ultrasound findings from
the acute episode through to recovery.

METHODS
From July 1998 to May 2004, all children who had
intermittent hydronephrosis and presented with abdominal pain were studied prospectively. Informed consent
was obtained from the parents of the children. The diagnosis of intermittent hydronephrosis required all of
the following criteria: (1) episodes of intermittent abdominal pain were associated with demonstrable UPJO
only during an attack or on provocative testing8; (2)
urinary tract infection was ruled out by finding a negative urine culture and no evidence of pyonephrosis on
ultrasonography; (3) vesicoureteral reflux was ruled out
by voiding cystourethrography (VCUG); (4) a renal
stone in the ureteropelvic junction was excluded by
plain abdominal film, ultrasonography, or computed tomography (CT) when necessary; and (5) the imaging
studies demonstrated obstructive hydronephrosis during
an acute attack but no obstruction during symptom-free
intervals.
Renal ultrasound was used as an initial screening tool
to detect intermittent hydronephrosis. All ultrasound
examinations were performed by 1 pediatric nephrologist using a Toshiba (Tokyo, Japan) SSA-260A scanner
with a 3.5-MHz transducer. The urinary tract was examined in both supine and prone positions. Hydronephrosis
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was defined and graded as follows: mild renal pelvic

dilatation (grade 1), only a slit of fluid in the renal pelvis;
mild hydronephrosis (grade 2), a dilated pelvis extending to the calyces and upper ureter; moderate hydronephrosis (grade 3), a dilated pelvis and calyces but normal
parenchyma; and severe hydronephrosis (grade 4), a
dilated pelvis and calyces associated with a thin or distorted parenchyma. Renal pelvic wall thickening was
defined as a circumferential hypoechoic rim delineated
on each side by thin hyperechoic lines, the rim being
thicker than 0.8 mm.9 The thickness of the pelvic wall
was measured with the patient lying prone. When
marked hydronephrosis was demonstrated by ultrasound during the symptomatic stage, an IVP and Tc-99m
diethylene triamine pentaacetic acid (DTPA) diuretic renal scan were performed as soon as possible. All patients
were evaluated preoperatively with a DTPA diuretic renal scan to confirm obstruction and assess split renal
function. Renal ultrasonography was repeated every 1 or
2 days to record serial changes in the hydronephrosis as
the patients progressed from the symptomatic to asymptomatic stages. When only mild hydronephrosis or a
nondilated pelvis was demonstrated on the initial ultrasonographic examination during the symptom-free
stage, the patient was asked to return during the next
attack for assessment. Immediate ultrasonography and
other imaging studies were performed at that time to
detect hydronephrosis. Once intermittent hydronephrosis secondary to UPJO was diagnosed and imaging studies were completed, surgery was suggested. Renal ultrasonography and DTPA diuretic renal scan were used for
follow-up. Data collected for the study included symptoms, physical examination, laboratory data, and imaging studies.
RESULTS
From July 1998 to May 2004, 18 patients (14 boys, 4
girls) received a diagnosis of intermittent hydronephrosis in our hospital. Their ages ranged from 4.1 to 15.2
years (mean: 7.5 years). All had unilateral intermittent
hydronephrosis, 16 on the left and 2 on the right. Three
had asymptomatic contralateral mild hydronephrosis
without progressive pelvic enlargement. All presented
with acute abdominal pain, 15 with a history of recurrences (beginning 2 months to 2 years [mean: 8.1
months] before diagnosis) and 3 during their first attack.
Three had a history of mild hydronephrosis noted on
prenatal ultrasonography but developed episodes of
acute pain only at an older age.
The clinical features and associated symptoms and
signs are shown in Tables 1 and 2. In most cases, the pain
was acute and sharp, with a sudden onset. It typically
lasted for 2 days, during which the children had difficulty finding a comfortable position. Acute episodes resolved spontaneously, followed by pain-free intervals
that ranged from days to months. The episodes were

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TABLE 1 Clinical Features in 18 Patients With Intermittent

Hydronephrosis
Clinical Features
Quality of the pain
Cramping
Dull
Peritoneal signs
Location of pain
Flank/back
Periumbilical
Epigastric
Diffuse abdominal
Duration of acute episode, d
1
12
23
Frequency of attacks
Once (the rst attack)
Every 1 wk
Every 2 wk
Every 4 wk
Every 23 mo
Precipitating factors
Increased uid intake
Vigorous exercise
Bladder lling during sleep
None identied

n (%)
16 (89)
2 (11)
1 (6)
14 (78) (Right: 2, left: 12)
4 (22)
4 (22)
1 (6)
6 (33)
10 (56)
2 (11)
3 (17)
3 (17)
6 (33)
4 (22)
2 (11)

FIGURE 1
CT of ruptured kidney. The patient had intense pain that woke him from sleep in the
morning. CT showed rupture of the right kidney with perinephric uid collection. Bloody
urine was drained via a percutaneous nephrostomy.

6 (33)
3 (17)
4 (22)
7 (39)

had nausea and vomiting. Bilious vomiting was noted in

4, and 1 had bloody vomitus. Other associated symptoms
and signs included hypertension (2 patients), urinary
retention (1 patient), urinary frequency (1 patient), and
intestinal ileus (1 patient). Ten of the patients initially
received a diagnosis of other diseases, including intestinal ileus (2 patients), appendicitis (1 patient), abdominal
mass (1 patient), renal stone (2 patients), chronic constipation (1 patient), gastrointestinal dysfunction (2 patients), and urinary tract infection (1 patient).
On ultrasonography, all patients had either moderate
(8 patients) or severe (10 patients) hydronephrosis in
the acute stage. During symptom-free intervals, 7 had
only mild pelvic dilatation and 9 had mild hydronephrosis; 2 patients had moderate hydronephrosis during recovery from acute hydronephrosis (Table 3). During
convalescence, all had renal pelvic wall thickening (Fig
2). This finding appeared on the second or third day after
pain had subsided. The hydronephrosis gradually decreased in degree. A thickened pelvic wall persisted for 6
to 9 days and then disappeared, with only a minimally
dilated pelvis present in the symptom-free stage. The
maximum measured thickness of the pelvic wall ranged
from 2.5 to 5.6 mm (mean: 3.4 mm). A diagnosis of
intermittent hydronephrosis was suspected in 8 patients
because of the finding of a thickened pelvic wall in the
convalescent period, although only mild hydronephrosis
was found on initial ultrasound examination. We recommended that they come for immediate ultrasonogra-

TABLE 2 Associated Symptoms and Signs During Acute Episodes

Associated Symptoms and Signs
Nausea and vomiting
Palpable abdominal mass
Gross hematuria
Microscopic hematuria
Hypertension
Urinary retention (dysuria)
Urinary frequency
Ileus on plain abdominal lm
Spontaneous rupture of kidney

n (%)
(N 18)
16 (89)
4 (22)
2 (11)
7 (39)
2 (11)
1 (6)
1 (6)
1 (6)
1 (6)

initiated or exacerbated by the ingestion of excess fluid

in 6 (33%) children and by vigorous physical activity in
3 (17%). Four children had acute attacks that woke
them from sleep early in the morning. One of them,
intermittent hydronephrosis secondary to UPJO, received the diagnosis during his previous hospitalization,
and he was scheduled for operation. He had intense,
intolerable pain in the morning and was subsequently
found on ultrasonography and CT to have spontaneous
rupture of the kidney with no history of trauma (Fig 1).
There were no identifiable precipitating factors in 7
(39%) patients; their pain occurred unpredictably. The
pain was predominantly in the left, periumbilical, and
epigastric areas. Older children might describe flank or
unilateral back pain. Children who were younger than 5
were less likely to describe the sensation accurately and
generally pointed to the periumbilical or epigastric region. In addition to abdominal pain, 16 (89%) children

TABLE 3 Degree of Hydronephrosis on Sonogram During Acute and

Symptom-Free Stages
Grade 1
Acute stage, n
Symptom-free stage, n

Grade 2

Grade 3

Grade 4
10

8
2

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141

FIGURE 2
Serial ultrasound ndings from the acute episode through to recovery. A, This 8-year-old boy had severe hydronephrosis at the painful stage. The pain lasted for 2 days. B, On the
second day after the pain had subsided, the size of hydronephrosis was gradually decreased. C. On the third day, the hydronephrosis was continuously decreased in degree, and
thickened pelvic wall was examined (arrowheads). D, The measured thickness of the pelvic wall was 3.2 mm in the prone position (arrowheads). E, The thickened pelvic wall persisted
for 6 days and disappeared on the ninth day.

phy during the next attack, and all were demonstrated to

have intermittent UPJO. After surgical correction, none
had a thickened pelvic wall on follow-up ultrasonography.
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TSAI, et al

Abdominal CT was performed in 8 patients, 3 in the

emergency department for evaluation of an acute abdomen, 1 to assess a palpable flank mass, 1 who exhibited
spontaneous kidney rupture, and 3 to exclude a ureteral

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stone. All patients were free of vesicoureteral reflux

according to VCUG. IVP was performed in 14 patients in
the acute period. Ten patients had delayed filling and
marked hydronephrosis without enlargement of the
ureter, suggestive of UPJO. In 4 patients, the involved
kidney appeared enlarged but functioned poorly secondary to acute obstruction. Only a small amount of contrast
medium was excreted into the pelvis, so the detailed
anatomy of the UPJ was not demonstrated clearly. Antegrade pyelography was done via a percutaneous nephrostomy in the patient with the ruptured kidney, and
UPJO was demonstrated. A DTPA diuretic renal scan was
performed in 17 patients within 3 days after the acute
attack. The preoperative split renal function ranged from
10% to 55% (mean: 35.5%) in the involved pelvis.
Fifteen patients had an obstructive pattern on washout
curves with prolonged half times. Two patients had an
equivocal pattern of the washout curve after furosemide.
Three patients noticed some discomfort on the hydronephrotic side during this test.
Open surgery was performed in 17 patients, including
a dismembered pyeloplasty in 16 cases and pyeloplasty
with ureteropelvic anastomosis in front of the crossing
vessel in 1. The other one was lost to follow-up. Intrinsic
obstructions, such as ureteral narrowing or an adynamic
segment, were noted in 6 (35%) patients. Extrinsic obstructions were found in 9 (53%) patients, including 6
with a kinked ureter, 2 with a high ureteral insertion,
and 1 with an aberrant vessel. Two (12%) patients had
a fibroepithelial polyp of the ureter. Only 7 (50%) of 14
cases were diagnosed correctly before operation by IVP,
including 3 cases of intrinsic stenosis, 2 of kinking of the
ureter, 1 ureteral polyp, and 1 aberrant vessel. Follow-up ranged from 4 months to 7.3 years, with a mean
of 3.6 years. Stable moderate hydronephrosis was found
in 2 (12%) kidneys and mild hydronephrosis in 7 (41%)
kidneys. Mild pelvic dilation was noted in the remaining
8 (47%) kidneys. Ultrasonography after operation
showed diminished hydronephrosis in all 17 children,
and the DTPA scans all showed improved drainage
curves. The postoperative split renal function ranged
from 25% to 54% (mean: 46%). None of the children
had additional episodes of colicky pain after pyeloplasty.
Two children who had hypertension became normotensive shortly after release of the obstruction.
DISCUSSION
Classic UPJO, once it is suspected clinically, usually presents no diagnostic difficulty on radiologic study. However, intermittent hydronephrosis is a difficult condition
to identify, and it requires a different diagnostic approach. The pelvis is minimally dilated between episodes
of hydronephrosis. This condition accounted for only
3.4% of all patients who underwent pyeloplasty during
a 10-year period at the Mayo Clinic.10
Acute UPJO almost immediately produces symptoms.

The rapid development of hydronephrosis causes a direct

increase in the intraluminal pressure of the collecting
system, physically stretching the renal capsule and collecting system and stimulating nerve endings in the lamina propria.11 Therefore, the acute obstruction causes
pain, which is classically colicky in nature. The severity
of the pain correlates with the rate of onset of the
obstruction rather than the degree of distention. Even
moderate distention of the pelvis will result in severe
pain when it develops acutely. Intermittent hydronephrosis presents as recurrent, acute abdominal pain, a
pattern that is not necessarily specific for Dietls crisis,5 so
a detailed history of the pattern of pain and a thorough
physical examination are the keys to diagnosing this
condition. The history should include the location, nature, duration, frequency, precipitating factors, and timing of the episodes, along with associated symptoms.
Our patients all were older than 4 years and were
predominantly boys. The left kidney was more commonly involved than the right. The pain was typically
extremely intense, of sudden onset, cramping in nature,
and frequently associated with nausea and vomiting and
generally localized to the flank or back. However,
younger children may point to the periumbilical or epigastric areas. In most cases, the pain lasted for 48 to 72
hours followed by pain-free interval that ranged from
days to months. Gross or microscopic hematuria, which
was found in 50% of our patients, is an important clue
that narrows the diagnosis to the urinary system. It
results from acute stretching of the renal collecting system.2 Less common associated symptoms and signs included palpable abdominal mass, hypertension, dysuria,
or urinary frequency. The association of hypertension
with Dietls crisis has been reported repeatedly.4,1214 It is
caused by activation of the renin-angiotensin system
secondary to reduced renal perfusion during acute ureteral obstruction.15 The 2 patients in our series with
hypertension became normotensive shortly after the obstruction was relieved. The colicky pain may be associated with gastrointestinal symptoms because of reflex
stimulation of the celiac ganglion and the proximity of
adjacent intraperitoneal organs.15 Seven (39%) of our
patients received a diagnosis of gastrointestinal inflammation, obstruction, or dysfunction in the absence of
typical urologic symptoms and signs such as back pain,
hematuria, hypertension, or dysuria. Urinary tract infection and ureteral or pelvic calculi also have similar presentations and should be ruled out before diagnosing
intermittent hydronephrosis.
Although inciting factors such as increased water intake or use of diuretics have been reported in 40% of
patients with intermittent hydronephrosis,3,4,10 the actual
pathophysiology of intermittent obstruction is not clear.
Koff et al16 reported that extrinsic mechanical disturbances that occur alone or coexist with intrinsic UPJO
predisposed the kidney to intermittent hydronephrosis
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because of the volume-dependent restriction to pelvic

emptying during diuresis. Mechanical obstruction is activated and resistance that is caused by the obstruction
increases suddenly when pelvic volume expands and the
pressure is increased. However, nearly 40% of our patients had no obvious precipitating events; their acute
attacks occurred unpredictably, consistent with many
other reports in the literature.3,1719 Three of our patients
had symptoms precipitated by vigorous exercise, a factor
also noted by Flotte et al.4 It is interesting that 4 children,
including the 1 whose kidney ruptured, had acute pain
in the early morning, presumably precipitated by filling
of the bladder overnight. It is reported that the degree of
bladder filling and intravesical pressure are crucial factors that affect upper tract drainage.20 Bladder filling
decreases drainage of the upper tract, thus affecting upper tract pressure. Flank pain with obstruction may be
reproduced by filling the bladder in patients with potential obstructive uropathy,20 as was the case with our
patients.
Provocative tests that cause forced diuresis, such as
hydration, a diuretic IVP,10 diuretic ultrasonography,21
diuretic DTPA renal scan,8 or Whitakers pressure-perfusion study,16 sometimes may induce acute obstruction.
However, pain has not been reproducible uniformly
with these techniques; neither is any provocative test
guaranteed to reveal obstruction.10 Ultimate diagnosis
often requires that testing be performed during an episode of pain because this is the only way actually to
prove the diagnosis.10 Obstructive hydronephrosis on
any imaging study when the patient is having pain, with
nonobstructive hydronephrosis or normal findings after
the pain is gone, strongly suggests the diagnosis of intermittent hydronephrosis. Therefore, multiple repeated
imaging studies may be required to demonstrate rapid
changes in renal anatomy during the development and
the resolution of acute hydronephrosis.
Ultrasound is the preferred screening modality in the
evaluation of intermittent hydronephrosis. It is noninvasive, quick, and repeatable; does not involve contrast
media exposure or ionizing radiation; and is also useful
in evaluating other organs to exclude other causes of
abdominal pain. Ultrasound has high sensitivity for detecting hydronephrosis.22 Therefore, if a symptomatic
patient has no or only mild dilation of the pelvis, then
intermittent hydronephrosis can be excluded. UPJO is
suspected when the renal pelvis is enlarged during an
acute episode in the absence of ureteral dilation. However, from our point of view, demonstration of decreasing pelvis size after an attack is as important as is demonstrating marked hydronephrosis in the acute stage. If
the hydronephrosis cannot be shown to decrease, then it
is a chronic rather than an intermittent condition. In
that case, the relationship between the pain and the
hydronephrosis is unclear.
By the time a patient is evaluated by ultrasound, the
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obstruction may have resolved so that the hydronephrosis has disappeared or there remains only mild dilation of
the renal pelvis. Mild hydronephrosis can occur in patients with normal variants, bladder distention, vesicoureteral reflux, and chronic nonobstructive hydronephrosis. In addition, hydronephrosis can be found in
asymptomatic children, with a reported prevalence in
schoolchildren of 0.193% by portable ultrasound
screening.23 Therefore, the question is how to determine
when mild hydronephrosis indicates previous obstruction that has resolved, rather than some other condition.
From our study, we think that renal pelvic wall thickening on ultrasonography during convalescence is an
important clue to recent dilation of the pelvis. According
to Robben et al,24 the normal pelvic wall thickness in
normal children ranges from 0.1 to 0.8 mm. They suggested a threshold of 0.8 mm as a reliable discriminator
for pathologic conditions. All of our patients had much
thicker pelvic walls, ranging from 2.5 to 5.6 mm. A
thickened pelvic wall is reported to occur in various
diseases, including acute pyelitis,9,2426 vesicoureteral reflux,9,2426 rejection of a renal transplant,27 acute tubular
necrosis,28 congenital hydronephrosis after pyeloplasty,28
mobile nephrolithiasis,29 and structural causes of intermittent dilation of the collecting system.24
Three groups have mentioned the relationship between UPJO and pelvic wall thickening. Babcock et al28
first reported it in patients with UPJO after pyeloplasty.
Sorantin et al26 reported 4 cases of UPJO with renal
pelvic wall thickening, but the clinical presentation in
those cases was not described. Robben et al24 recently
evaluated the significance of renal pelvic wall thickening
and found that intermittent dilation of the collecting
system was an important cause. If vesicoureteral reflux
is excluded, then the differential diagnosis of a thickened
renal pelvic wall includes a high-pressure bladder, primary obstructing megaureter, and UPJO. However,
none of these studies determined the incidence of pelvic
wall thickening, the timing of its occurrence, or the
duration of recovery in patients with intermittent hydronephrosis. In all of our patients, pelvic wall thickening appeared on the second or third day after a painful
episode subsided, at the time when the degree of hydronephrosis was gradually beginning to decrease. The
thickened wall then persisted for 6 to 9 days and disappeared during the symptom-free stage, when very slight
pelvic dilation was present.
The pathophysiology of renal pelvic wall thickening
in intermittent hydronephrosis relates to the acute ureteral obstruction that produces hyperperistalsis and high
intrapelvic pressure.30 The thickening of the wall may be
caused by subepithelial edema or an acute inflammatory
response of the collecting systems. Increased stretching
of the pelvis and high intrapelvic pressure further traumatize the wall, inducing additional edema and inflammation. However, during an acute episode, significant

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hydronephrosis obliterates a clear view of the wall on

ultrasound so that the thickening is apparent only after
the obstruction is relieved and hydronephrosis diminishes.27 The resolution of edema and inflammation is followed by return of the wall to its normal thickness. In
our series, the thickness of the pelvic wall completely
normalized during follow-up, an additional confirmation of the intermittent nature of this entity. We therefore believe that the diagnosis of intermittent hydronephrosis could be made in most cases by a careful history,
a physical examination, and serial ultrasound studies
that follow the condition from the acute stage through
convalescence to recovery.
Although ultrasound is useful in diagnosing intermittent hydronephrosis, it does not delineate the cause of
UPJO or permit functional evaluation of the kidney.
Therefore, additional imaging studies may be needed
before surgical intervention is undertaken. Non contrast-enhanced CT accurately detects and characterizes
obstructing renal and ureteral calculi.31 If no stone is
present, then CT accurately identifies other causes of
flank or abdominal pain.7 Therefore, CT is an effective
initial imaging tool for evaluating suspected renal colic.11
In our patients, because most of their conditions were
diagnosed by a detailed history and ultrasound, CT was
performed only in patients without a typical history of
recurrent pain, when ureteral stone was suspected, or
when the symptoms were very atypical or very acute. A
VCUG is required to exclude vesicoureteral reflux. IVP
has significant limitations in the evaluation of hydronephrosis in patients with a poorly functioning kidney or
an extremely dilated pelvis. However, an IVP identifies
the site of obstruction in a substantial number of cases
and depicts the anatomy of UPJ. Of the 14 patients in our
series who had an IVP, the correct diagnosis was apparent in only half. IVP is particularly helpful in evaluating
the mechanism of obstruction in intermittent hydronephrosis, which mostly exhibits an extrinsic component.26 Diuretic renal scan is the most widely used technique to assess the function and drainage of the kidneys
in the presence of hydronephrosis. Although a delayed
double-peak sign on diuretic renal scan is thought to be
diagnostic of intermittent hydronephrosis during symptom-free intervals,8 it still is necessary to demonstrate
obstructive hydronephrosis during an acute attack before proceeding to surgery. As with ultrasonography, an
IVP or a diuretic renal scan is best performed in the
symptomatic period. We believe that the timing of diagnostic studies is actually more important than the imaging modality used.
UPJO may involve intrinsic25,8,17,32 or extrinsic components.5,8,10,19,32 Intrinsic narrowing or an adynamic segment of the ureter is characterized by a linear pressureflow response pattern with fixed resistance at the UPJ.
Extrinsic compression of the ureter produces a complex
volume-dependent response pattern with an acute self-

obstructing crisis after diuresis.16 Although extrinsic

causes of UPJO were recognized at operation in most
patients with intermittent hydronephrosis,25,8,17,32 intrinsic mechanisms were also repeatedly reported.5,8,10,19,32
Lebowitz33 believed that when a child presents with
UPJO because of symptoms, approximately half are
caused by extrinsic obstruction. In our patients, intrinsic
obstruction was present in 35% and extrinsic compression in 53%. Only 2 children had a fibroepithelial polyp
accounting for the disorder. Although aberrant vessels,
bands, adhesions, or kinks all have been implicated in
UPJO, Homsy et al8 suggested that other factors may be
involved, although such factors have yet to be identified.
Koff et al16 suggested that extrinsic and intrinsic UPJO
may coexist to produce intermittent hydronephrosis.
Park et al34 also concluded that most patients likely had
1 possible cause of obstruction. They stated that most
UPJO caused by either intrinsic stenosis or aberrant vessels also had secondary obstruction, such as anomalous
insertions and periureteral fibrosis. Therefore, coexisting
intrinsic and extrinsic causes must be considered and
assessed intraoperatively. In addition to relief of extrinsic
compression, intrinsic stenosis requires appropriate
management. For most patients, dismembered pyeloplasty is adequate in this regard. In general, pyeloplasty
relieves the pain and obstruction and ensures excellent
functional recovery. Good renal function is expected in
most of these children, because the obstruction is transient. We believe that intermittent hydronephrosis is an
absolute indication for surgery. Without correction,
there is the potential for irreversible hydronephrosis culminating in severe renal dysfunction5 or even rupture of
the kidney, as occurred in 1 of our patients.

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RANDOMIZED TRIALS STOPPED EARLY FOR BENEFIT: A SYSTEMATIC REVIEW

Context: Randomized clinical trials (RCTs) that stop earlier than planned
because of apparent benefit often receive great attention and affect clinical
practice. Their prevalence, the magnitude and plausibility of their treatment
effects, and the extent to which they report information about how investigators decided to stop early are, however, unknown. . . .
Data Synthesis: Of 143 RCTs stopped early for benefit, the majority (92)
were published in 5 high-impact medical journals. Typically, these were
industry-funded drug trials in cardiology, cancer, and human immunodeficiency virus/AIDS. The proportion of all RCTs published in high-impact
journals that were stopped early for benefit increased from 0.5% in 1990
1994 to 1.2% in 2000 2004 (P .001 for trend) . . .
Conclusions: RCTs stopped early for benefit are becoming more common,
often fail to adequately report relevant information about the decision to stop
early, and show implausibly large treatment effects, particularly when the
number of events is small. These findings suggest clinicians should view the
results of such trials with skepticism.
Montori VM. JAMA. 2005;294:22032209
Noted by JFL, MD

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TSAI, et al

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Intermittent Hydronephrosis Secondary to Ureteropelvic Junction Obstruction:

Clinical and Imaging Features
Jeng-Daw Tsai, Fu-Yuan Huang, Chun-Chen Lin, Tsuen-Chiuan Tsai, Hung-Chang
Lee, Jin-Cherng Sheu and Pei-Yeh Chang
Pediatrics 2006;117;139
DOI: 10.1542/peds.2005-0583
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2006 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Intermittent Hydronephrosis Secondary to Ureteropelvic Junction Obstruction:

Clinical and Imaging Features
Jeng-Daw Tsai, Fu-Yuan Huang, Chun-Chen Lin, Tsuen-Chiuan Tsai, Hung-Chang
Lee, Jin-Cherng Sheu and Pei-Yeh Chang
Pediatrics 2006;117;139
DOI: 10.1542/peds.2005-0583

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/117/1/139.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2006 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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