Comparison of Retrograde Endo-Pyelotomy and Endo-Balloon Rupture of the Ureteropelvic Junction in a Porcine Model

Abstract

Excellent results and durable success have been achieved with antegrade and retrograde endo-pyelotomy for treating primary and secondary ureteropelvic junction obstruction. Recently, a 30F dilating balloon was used to rupture the ureteropelvic junction (ENDOBRST) with encouraging results. While balloon distention of the ureteropelvic junction is a technically simpler procedure than endo-pyelotomy, clinical and laboratory data comparing the 2 methods are lacking. In an acute and chronic animal study we compared endo-pyelotomy via a ureteral cutting balloon incision to balloon rupture (that is 30F) of the normal ureteropelvic junction in each of 20 female farm pigs. Eight pigs were harvested acutely after treatment, and a macroscopic and histological examination of the treated ureteropelvic junction was completed. In 11 chronic pigs after endo-pyelotomy a 7F double pigtail ureteral stent was placed bilaterally and then removed after 6 weeks. Evaluation in the chronic group consisted of a furosemide washout renogram and retrograde pyelogram immediately preoperatively and 6 weeks after stent removal. The animals were likewise harvested 6 weeks after stent removal. One control pig underwent passage of the balloon cutting catheter and balloon dilating catheters without activation or dilation, respectively. Ureteral stents were placed bilaterally for 6 weeks and the pig was otherwise treated similarly to the other chronic study animals.In the acute group all ureters after endo-pyelotomy demonstrated retroperitoneal extravasation of contrast material. At harvest the ureters had been cleanly incised along a length of 3 to 4cm. through the adventitial layer. In contrast, the balloon treated ureters showed free retroperitoneal extravasation in only half of the animals. Among the balloon treated ureters 7 of 8 had a linear tear of varying length (1 to 5cm.) involving all but a thin adventitial layer of tissue. Histologically, the endo-pyelotomy ureters demonstrated a clean, linear transmural incision with virtually no destruction of surrounding tissue in 6 cases. In the remaining 2 cases an incision into but not completely through the muscular layer was observed. The balloon treated ureters showed a perforation through the muscular wall in 7 cases. However, periureteral hemorrhage and urothelial loss were common findings.In the chronic group infection and continued urine extravasation from the endo-pyelotomy site resulted in a 45% mortality rate. Of the surviving 6 pigs 83% of the balloon treated and 67% of the endo-pyelotomy pigs had a patent ureteropelvic junction by retrograde pyelogram and renogram. Histologically, the 2 sides were indistinguishable, with both showing mild fibrosis and chronic inflammation.Overall, in the acute phase endo-pyelotomy provides a well defined, full thickness incision of the ureteropelvic junction. In contrast, balloon rupture of the ureteropelvic junction results in a ureterotomy of unpredictable length, breadth and depth. However, histologically, the 2 modalities are comparable in the chronic phase. In this study balloon distention appeared to be safe and as efficacious as an endo-pyelotomy. The potential clinical relevance of these findings requires further study.