Bilateral Ureteropelvic Junction Obstruction Research Articles

Robotic-Assisted Laparoscopic Pyeloplasty in Challenging Cases of Ureteropelvic Junction Obstruction in the Pediatric Population: A Multicenter Review.

Purpose: To report a multi-institutional international experience in performing robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO) in the pediatric population and assess feasibility and outcomes. Materials and Methods: Retrospective chart review of all pediatric patients who underwent robotic-assisted laparoscopic pyeloplasty (RALP) for UPJO in challenging cases between 2013 and 2021 was included. Demographics, perioperative surgical data, complications, and results are described. Challenging cases were defined as bilateral UPJO, failure of previous open pyeloplasty (thus re-do cases), correction of UPJO in kidneys with anatomical variations, huge hydronephrosis, and low-weight infants (<6 kg). Results: Over an 8-year period, 36 children (62% males and 38% females) met the inclusion criteria for our study. Fifteen patients underwent RALP for recurrent UPJO; among them, 2 children required simultaneous surgery for renal stones, 3 cases of lower pole UPJO in double collecting system, 3 cases of pelvic and horseshoe kidneys, 10 cases of infants weighing <6 kg, 3 cases of huge hydronephrosis, and 2 cases of bilateral UPJO. The median age and weight were 36 months (interquartile range [IQR] 14-84) and 12 kg (IQR 10-20.5), respectively. All robotic cases were completed successfully with no conversion to an open procedure. The median operative time was 120 minutes (IQR 90-135). The mean length of hospital stay was 2.6 days. Four patients (17%) had postoperative complications-1 ileus (Clavien-Dindo grade [CDG] I) and 3 urinary tract infections (CDG II). No CDG III or higher complication was encountered. At a median follow-up of 36 months, the success rate was 95% with 1 patient requiring another re-do procedure due to recurrent obstruction. Conclusions: Our data suggest that RALP is safe and effective even for challenging cases of UPJO in children.

V01-10 BILATERAL TESTICULAR VEIN SYNDROME MASQUERADING AS BILATERAL URETEROPELVIC JUNCTION OBSTRUCTION- LESSONS LEARNT

You have accessJournal of UrologyCME1 Apr 2023V01-10 BILATERAL TESTICULAR VEIN SYNDROME MASQUERADING AS BILATERAL URETEROPELVIC JUNCTION OBSTRUCTION- LESSONS LEARNT Ravimohan mavuduru, Shantanu Tyagi, Girdhar Bora, and Shrawan Singh Ravimohan mavuduru Ravimohan mavuduru More articles by this author , Shantanu TyagiShantanu Tyagi More articles by this author , Girdhar BoraGirdhar Bora More articles by this author , and Shrawan SinghShrawan Singh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vascular compression of ureter by aberrant lower polar vessels, retrocaval compression and ovarian vein has been described in the past. Still rarer is the ureteric obstruction with the crossing of testicular vein. We present a case of Bilateral testicular vein syndrome masquerading as Ureteropelvic junction obstruction (UPJO), its intra-operative diagnosis and management. METHODS: Index patient is a 18-year-old male, presented with history of bilateral flank pain since 7 months, colicky in nature, requiring intravenous analgesics. There was no significantly contributing past history. He was evaluated elsewhere with abdominal ultrasonography which was suggestive of bilateral gross hydronephrosis. Non-contrast computed tomography (NCCT), done during an acute episode revealed bilateral gross hydronephrosis with probable site of obstruction at UPJ. Diuretic renography in the form of DTPA Scan consolidated the findings of NCCT revealing bilateral compromised cortical function and obstruction to outflow at UPJ. With the given history and evaluation, patient was diagnosed to have Bilateral UPJO and planned for bilateral robot-assisted pyeloplasty. Intraoperatively, on the left side, at pyelotomy the ureter seemed dilated across UPJ raising questions over pre-operative diagnosis. Consequently distal patency check was undertaken to confirm the site of obstruction. After gentle distal ureteric dissection, extrinsic compression at the site of crossing left testicular vein was found to be the site of actual ureteric obstruction. To relieve this compression, the ureter was super positioned over a posteriorized gonadal vein with a subsequently successful distal patency check. Taking lessons from the left side, we started with distal ureteric dissection and surprisingly found extrinsic compression with right testicular vein on the right side as well. Site of compression was visualised as fibrosed ureteric segment which was excised and ureteroureterostomy was done super positioned over a posteriorized right gonadal vein. RESULTS: The patient had an uneventful post-operative course and bilateral double-J stents were removed at 3 weeks. Follow-up renogram at 3 months documented the resolving bilateral hydronephrosis and unobstructed drainage. CONCLUSIONS: Lessons learned from the given case are- Contrast-enhanced CT imaging could have suggested ureteric compression with gonadal vein pre-operatively, Distal patency check is vital when there is dilatation across PUJ, When in doubt, distal ureteric dissection is a better approach and preservation of ureteric vascularity is of paramount importance. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e82 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ravimohan mavuduru More articles by this author Shantanu Tyagi More articles by this author Girdhar Bora More articles by this author Shrawan Singh More articles by this author Expand All Advertisement PDF downloadLoading ...

The sequence of intervention determines the risk of early postoperative acute kidney injury in infants with bilateral ureteropelvic junction obstruction

The management of bilateral ureteropelvic junction obstruction (UPJO) is greatly debated. We aim to identify the risk of early postoperative acute kidney injury (AKI) in relation to the sequence of intervention in children with bilateral UPJO managed in a sequential manner. A single center database was retrospectively reviewed for children ≤2 years who underwent bilateral pyeloplasty. According to the differential renal function on the preoperative renograms, patients were categorized into group A: pyeloplasty on the poorer functioning kidney first and group B: pyeloplasty on the better functioning side first. Serum creatinine and eGFR, using the modified Schwartz formula, were evaluated at four time points (I): before the first intervention (II): within 48h of the first intervention (III): before the second intervention and (IV): within 48h of the second intervention. Preoperative and postoperative values were compared. The incidence of early postoperative AKI in both groups was defined according to the Acute Kidney Injury Network (AKIN) criteria. The study comprised 46 children treated by staged pyeloplasty, 28 of them underwent pyeloplasty on the poorer functioning side first. Baseline serum creatinine and eGFR were not significantly different between both groups. Patients who underwent pyeloplasty on the poorer functioning side first, had a significant decline of eGFR after the first intervention (p=0.006). Conversely, no significant eGFR changes were observed after the first or second interventions in the other group (figure). Overall, 64.3% and 33.3% of patients developed some degrees of AKI when intervention was started on the poorer and better functioning renal units, respectively (p=0.04). Bilaterality is seen in approximately ¼ of patients with UPJO. Oftentimes, both renal units are asymmetrically affected with little data to guide surgeons on the optimal sequence of intervention. Following pyeloplasty, 52.2% of the evaluated children with bilateral UPJO had early postoperative AKI, mostly of low stage. Our data suggest that intervening first on the better functioning side allows for better recovery of the renal functional reserve and lowers the risk of postoperative AKI. In children with bilateral UPJO, starting intervention on the poorer functioning kidney is associated with increased risk of postoperative AKI. Long-term prospective studies are needed to confirm our findings.

Acute bilateral ureteropelvic junction obstruction as a rare cause of hypertensive crisis: a case report

BackgroundBilateral ureteropelvic junction obstruction is a common cause of secondary hypertension in the pediatric population, often due to congenital malformation. On the other hand, it is less frequently encountered in the adult population and is usually due to an acquired condition, most commonly by a bilaterally obstructing nephrolithiasis causing hydronephrosis and subsequent hypertension. The aim of this study was to investigate and highlight the underlying mechanisms by which acute bilateral ureteropelvic junction obstruction causes hypertensive crisis and why early detection and prompt treatment are necessary to mitigate the effects of elevated blood pressure on target organs.Case presentationA 41-year-old African American man with hypertensive cardiomyopathy presented with anuria. He was found to have elevated blood pressure with evidence of target organ damage on laboratory examination, demonstrated by sudden elevation of his serum creatinine level. He was initially treated with oral and intravenous antihypertensives, with minimal improvement. The work-up was unremarkable apart from the imaging finding of acute bilateral ureteropelvic junction obstruction from obstructing nephrolithiasis causing hydronephrosis. Bilateral ureteral stents were placed for decompression, with resolution of the hypertensive crisis and improvement of renal function.ConclusionThis case highlights the importance of prompt diagnosis and treatment of underlying acute bilateral ureteropelvic junction obstruction to mitigate the deleterious effects of sudden blood pressure elevation on target organs.

Pyeloplasty in children with low differential renal function: Functional recoverability

Ureteropelvic junction obstruction (UPJO) is a common pathology in pediatric urology practice. Indications for intervention are well established while the ideal management of children with UPJO in poorly functioning kidneys is still debatable. We aimed in this study to evaluate the outcome of pyeloplasty in patients with UPJO and low DRF ≤20%. We retrospectively evaluated 218 children with congenital UPJO from two tertiary hospitals between 2008 and 2018. We included only those with primary unilateral UPJO and DRF ≤20% on diuretic renography. Open dismembered pyeloplasty with stenting was carried out in all. Patients with bilateral UPJO, solitary kidney, DRF above 20%, association with other urinary anomalies and patients who underwent previous renal or ureteric surgeries and patients with missed follow-up were excluded. Clinical and radiological outcomes of this subgroup of patients were assessed. A total of 21 patients (12 boys, 9 girls) with a median age at surgery of 2 years were included. Preoperative DRF ranged from 8 to 20% with a mean of 15%±3.5%. The median follow-up period was 2.5 years. Renal ultrasound showed improved HN in 16 patients (4 had a complete resolution) and stable in the remaining 5. Most of the improvement was noted in the first postoperative ultrasonography 16/21 (76%). Diuretic renography showed improved DRF by 10-15% in 8 patients (38%) while the remaining patients showed stable DRF with a non-obstructive curve with a mean improvement in DRF of 8±5%. No postoperative complications were encountered and none of our patients required reintervention during follow-up. The ideal management of children with UPJO and poorly functioning kidneys is still arguable. In our study we evaluated the outcome of pyeloplasty in patients with a low DRF ≤ 20% aiming to test the patients' variables that can affect the improvement of DRF and HN grade after surgical intervention, however, none of these preoperative variables seemed to be a significant predictor. Children with unilateral UPJO and DRF ≤ 20% have a favorable outcome after pyeloplasty. Improvement of HN in the first postoperative renal ultrasound is a good indicator for success.

Use of double-J ureteric stents post-laparoscopic pyeloplasty to treat ureteropelvic junction obstruction in hydronephrosis for pediatric patients: a single-center experience.

ObjectivesWe aimed to investigate the safety concerns associated with placing double-J ureteric stents post-laparoscopic pyeloplasty surgery for congenital ureteropelvic junction obstruction (UPJO) and hydronephrosis.MethodsA total of 1349 patients with postoperative double-J stent placement at our center were included. Clinical variables for enrolled patients were collected by two independent authors. We compared clinical variables and the efficacy of stenting post-laparoscopic pyeloplasty.ResultsThe mean age of the patients was 4.23 ± 2.39 years. A total of 58.49% of patients were diagnosed with left UPJO with hydronephrosis and 33.95% were diagnosed with right UPJO. Furthermore, 7.56% of patients had bilateral UPJO. In all cases, 96.96% of indwelling double-J stents were successfully removed 4 weeks post-surgery. A total of 3.04% of the patients still required further management, including stent migration to the renal pelvis (0.37%), stent migration to the bladder (0.30%), prolapse of the stent through the ureter (0.15%), blockage of stents (1.85%), and fouling of stents (0.37%).ConclusionsDouble-J ureteric stents used after laparoscopic pyeloplasty for treating UPJO in hydronephrosis for pediatric patients is a safe, feasible, and beneficial method, which can be recommended for routine procedures. However, caution should be practiced for follow-up and removal using this method.

Changes in differential renal function after pyeloplasty in infants and children

Ureteropelvic junction obstruction (UPJO) is one of the most common causes of hydronephrosis in pediatric populations. Many need surgical intervention. The aim of surgery is preserving renal function and reducing symptoms such as urinary tract infections and pain. The objectives were to evaluate differential renal function (DRF) in infants and children after surgery for UPJO and to identify factors predicting postoperative improvement. The difference in outcomes between patients with antenatal hydronephrosis and those diagnosed later was evaluated. A total of 85 children (63 boys and 22 girls) aged 0-16 years, treated for UPJO with dismembered pyeloplasty, were followed up as per a structured protocol including ultrasounds and renal scans (MAG-3) pre-operatively and three and 18 months postoperatively. Five children with bilateral or single kidney UPJO were excluded. Patient records were retrospectively reviewed, and the patients were grouped as per prenatal (group 1, n=23) or postnatal (group 2, n=57) diagnosis. Univariable and multivariable logistic regression analyses searching for factors predicting >5% postoperative improvement in DRF on the obstructed side were performed. Factors included in analyses were age at diagnosis and surgery, sex, type of presentation, cause of obstruction, estimated glomerular filtration rate, pre-operative DRF, anteroposterior diameter (APD), APD/renal parenchymal thickness, and grade of hydronephrosis as per the Onen alternative grading system (grade 1-4). Pre-operative DRF on the obstructed side was a mean of 42% (standard deviation, 12), with no difference between the groups. The median age at surgery was 0.9 (0.2-10) and 8.1 (0.6-16) years in groups 1 and 2, respectively (P<0.001). The majority had unchanged DRF 18 months postoperatively, 19 (27%) patients improved by >5%, and one deteriorated. The proportion of patients with improved DRF was higher in group 1 (n=10; 45%, P=0.026). Anteroposterior diameter, APD/parenchymal thickness, pre-operative DRF, and antenatal diagnosis were predictors in the univariable analyses, and high APD (odds ratio [OR] = 1.1, P=0.0023), antenatal diagnosis (OR = 0.23, P=0.048), and low pre-operative DRF (OR = 0.90, P=0.0045) built the best model of independent factors predicting improvement in DRF in multivariable analyses (Summary Figure). The limitation of the study is that it is retrospective, but it has the advantage of auniform follow-up protocol, including patients from a five-year period, with few lost to follow-up. The results can be of interest in evaluating factors of importance for predicting recovery of function in obstructive uropathies in children. The majority of children had preserved or improved function after surgery for UPJO. Those with an antenatal diagnosis displayed a greater ability to catch up in DRF, and high APD, antenatal diagnosis, and low pre-operative DRF were independent predictive factors of an improvement in renal function after pyeloplasty.

Postnatal management of bilateral Grade 3-4 ureteropelvic junction obstruction.

Introduction:Bilateral hydronephrosis on prenatal ultrasound can be managed expectantly or with surgical intervention. The treatment strategies and outcomes are not clearly defined.Methods:We conducted a retrospectively audit of outcomes of management of prenatally detected severe bilateral ureteropelvic junction obstruction (UPJO) in our institution.Patients with bilateral Grade 3–4 hydronephrosis were included. Those with complications like rupture, underwent bilateral intervention within 4 weeks; in the remaining, unilateral pyeloplasty was performed at 4–12 weeks. The contralateral renal unit was re-evaluated at a later date for further improvement or deterioration. All the patients were followed up with ultrasonography and renogram at 3 months, 6 months, and 1-year post operatively. The case records were analyzed for the resolution of antero-posterior diameter (APD) or the improvement in single-kidney glomerular filtration rate (s-GFR) in the operated units.Results:Over 15 years, 28 patients (56 renal units) had bilateral UPJO (male-to-female ratio = 13:1). Twelve units underwent neonatal intervention to tackle the complications (6 bilateral pyeloplasty), 17 units underwent early pyeloplasty, and 15 underwent late pyeloplasty. Twelve of the twenty-two (54%) contralateral units, which were stented/observed, resolved spontaneously. Receiver operating characteristics analysis revealed that those with initial APD <25 mm and initial s-GFR >35 ml/m were more likely to improve during the observation. Ten of the forty-four operated units (22%) failed to show an improvement. Units with initial s-GFR <10 ml/m had poor chance of postoperative functional recovery.Conclusions:In neonates with bilateral UPJO, the worse affected kidney is operated first, as it still has the potential to recover. The contralateral milder UPJO unit is known to recover spontaneously following unilateral pyeloplasty. In those with bilateral Grade 4 UPJO and mass, bilateral pyeloplasty is feasible. Alternatively, unilateral pyeloplasty + contralateral cystoscopic retrograde stenting may prevent rupture or functional deterioration in the opposite kidney.

Bilateral Ureteral Obstruction Related to Pelvic Rhabdomyosarcoma Presenting with Acute Kidney Injury: A Case Report

Bilateral renal obstruction is a rare critical condition, requiring a prompt diagnostic approach and treatment to restore the renal function. The most commonly observed obstructive uropathy in children is congenital malformation, such as posterior urethral valves and bilateral ureteropelvic junction obstruction. Malignant pelvic masses obstructing the ureter are widely reported in adults but are rarely observed in children. The treatment of ureteral obstruction related to pelvic malignancy is a therapeutic challenge with a median survival duration of 3–7 months in adults; however, pediatric patients with pelvic malignancy leading to ureteral obstruction had better outcomes, with a reported 5-year mortality rate of 20%, than the adult patients. Here, we report a rare case of bilateral ureteral obstruction associated with pelvic rhabdomyosarcoma presenting with acute kidney injury treated by ureteral diversion with double J stent, and concommittent emergency hemodialysis, leading to restoration of good renal function. We suggest that bilateral ureteral obstruction should be released as soon as possible using surgical or interventional approach to minimize the obstruction period, and subsequential chemotherapy may contribute to improvement of survival and recovery of renal function. Key words: Urinary bladder neck obstruction, Acute kidney injury, Child, Pelvic Neoplasms, Prognosis

BILATERAL URETEROPELVIC JUNCTION OBSTRUCTION: FACTORS GUIDING MANAGEMENT

Background: The management of prenatally detected hydronephrosis due to bilateral ureteropelvic junction obstruction (UPJO) remains controversial. No definite recommendations exist regarding management, and many authors recommend unilateral or bilateral pyeloplasty. Objective: This study was conducted to evaluate the clinical outcome of patients with bilateral UPJO treated at a tertiary care hospital. Materials and Methods: This descriptive study was performed in the Department of Pediatric Surgery, Lucknow. All patients with prenatally diagnosed bilateral hydronephrosis and postnatal diagnosis of bilateral UPJO, who underwent initial unilateral pyeloplasty, were prospectively evaluated and were included in the study. The outcome of contralateral hydronephrosis was assessed as resolution or surgery. Results: A total of 16 patients underwent initial unilateral pyeloplasty and met the inclusion criteria (mean age: 2.6 months). Of all 16 patients, 12 (75%) had resolution and 4 (25%) patients required additional contralateral pyeloplasty during the follow-up. The mean follow-up period was 18 months (range 9–36 months) and the mean anteroposterior pelvic diameter and pelvis-to-cortex (P/C) were significantly different among the groups (p<0.01). Conclusion: Our findings suggest that in children with bilateral UPJO type of hydronephrosis, improvement or resolution of the contralateral renal unit can occur following initial unilateral pyeloplasty for the worse renal unit. In patients in whom both the renalunits have similar split renal function and grades of hydronephrosis, pelvic AP diameter, cortical thickness, and P/C ratio can be used to determine the likelihood of contralateral delayed pyeloplasty.

Bilateral ureteropelvic junction obstruction with ureteric stone in a female Nigerian infant: the necessity for renal and urinary tract ultrasound in acute kidney injury running head: bilateral ureteropelvic junction obstruction

Bilateral ureteropelvic junction obstruction with ureteric stone in a female Nigerian infant: the necessity for renal and urinary tract ultrasound in acute kidney injury running head: bilateral ureteropelvic junction obstruction

Elevated urinary lipocalin-2, interleukin-6 and monocyte chemoattractant protein-1 levels in children with congenital ureteropelvic junction obstruction

In children with congenital ureteropelvic junction obstruction (UPJO), urinary biomarkers could assist in the diagnosis of renal damage or kidneys at risk for damage. Urinary levels of interleukin-6 (IL6), neutrophil gelatinase-associated lipocalin (LCN2), monocyte chemoattractant protein-1 (MCP1), and transforming growth factor-β1 (TGFB1) proteins have been correlated with renal damage in several contexts. Whether they might be useful non-invasive biomarkers of obstructive nephropathy due to unilateral and bilateral congenital UPJO was tested. A cohort study was performed at People's Hospital of Xinjiang Uygur Autonomous Region in China. Bladder urine samples from 17 patients with UPJO were obtained before surgical intervention and from 17 healthy age-matched controls. Levels of IL6, LCN2, MCP1, and TGFB1 were determined by enzyme-linked immunosorbent assay and normalized to urinary creatinine levels. Levels of urinary LCN2, MCP1, and IL6 were significantly elevated in the urine from individuals with UPJO compared with controls (P=0.0003, P=0.0003, and P=0.0073, respectively). Children with bilateral UPJO (n=5) showed significantly higher levels of IL6, LCN2, and MCP1 protein in their urine compared with controls or those with unilateral UPJO (n=12; P=0.007, P<0.0001, and P=0.0002, respectively). Combining LCN2 and MCP1 slightly improved biomarker performance. Urinary biomarkers could be used in obstructed patients to monitor for renal damage and might find particular utility on patients with bilateral UPJO. Monitoring urinary biomarkers and imaging features in untreated patients could provide insights into the natural history of renal damage due to obstruction and will be necessary to test their performance characteristics as biomarkers. Urinary levels of LCN2 and MCP1 protein are promising biomarkers monitoring children with UPJO, particularly in those with bilateral disease.

Devastating Renal Injury After a Low Energy Trauma: Was the Force Sufficient?

Introduction: Renal traumas are quite commonly encountered in emergency departments. Low-energy traumas are often considered non-significant, but the presence of a pre-existing renal lesion predisposes the kidneys to more severe damage in the setting of even minor traumas, which may be accompanied by devastating results, should they remain unattended. Case Presentation: Here we report an incidental diagnosis of bilateral ureteropelvic junction obstruction in a patient who presented with unexpected shattered kidney following a low-energy flank injury. Conclusions: Patients with a pre-existing renal lesion are vulnerable to severe traumatic renal injuries, even after minor trauma. The severity of renal injuries may be much more than expected, making the clinical and imaging findings complex and confusing in these patients.

Predictors of Renal Functional Improvement After Pyeloplasty in Ureteropelvic Junction Obstruction: Clinical Value of Visually Assessed Renal Tissue Tracer Transit in 99mTc-mercaptoacetyltriglycine Renography

To determine the clinical value of visually assessed renal tissue transit time (TTT) in 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) renography for patients undergoing pyeloplasty. Medical records of 164 patients who underwent dismembered pyeloplasty were retrospectively reviewed. Baseline and postoperative renal ultrasonography and 99mTc-MAG3 renography were performed. Two urologists blinded to clinical data evaluated the renography and classified TTT as timely or delayed based on visualization of the tracer in the kidney pelvis between 2 and 10 minutes. Renal functional change after pyeloplasty was compared between patients in the timely and delayed groups. A total of 126 patients (median age, 9 months) were evaluated after excluding patients with bilateral ureteropelvic junction obstruction, a single functioning kidney, duplicated ureter, or <3 months of follow-up. There were no differences between 89 patients with timely TTT and 37 patients with delayed TTT in mean preoperative hydronephrosis grade (3.7 vs 3.8) and pelvic diameter (3.1 cm vs 3.4 cm). Although the pre- and postoperative mean values of differential renal function (DRF) were significantly higher in the timely group than in the delayed group (47.2% vs 38.3% and 47.9% vs 44.6%), DRF change was greater in the delayed group (6.3% vs 0.6%). In multivariate analysis, delayed TTT was the only significant predictor of >5% improvement in renal function after pyeloplasty. Delayed TTT in 99mTc-MAG3 renography was a significant predictor of renal functional improvement after pyeloplasty in ureteropelvic junction obstruction. Because substantial improvement of renal function is anticipated, we recommend immediate pyeloplasty in patients with delayed TTT and decreased DRF.

Primary non-surgical management of unilateral ureteropelvic junction obstruction in children: a systematic review.

Ureteropelvic junction obstruction (UPJO) is the most common obstructive uropathy and its optimal management remains controversial. However, there is a current trend towards non-surgical management. We aimed to determine the effects of the non-surgical management in children with unilateral UPJO. For a systematic review, we searched MEDLINE, EMBASE, CENTRAL, clinical trials registries, and selected conference proceedings for eligible studies. Any type of study reporting the outcomes renal function, secondary surgical intervention, drainage pattern or hydronephrosis of non-surgical management in children with unilateral UPJO was included. Data from 20 studies were extracted and evaluated by two independent authors. The pooled prevalence was 21% for split renal function deterioration, 27.9% for secondary surgical intervention, 3.2% for progressive hydronephrosis, and 82.2% for improved drainage pattern. Not all patients with surgical intervention regained split renal function from enrolment. Renal imaging methods did not strongly correlate with each other. Many studies had to be excluded because of a lack of detection of an obstruction or mixed populations with bilateral UPJO or other uropathies. The variable definitions of UPJO, different criteria for surgical intervention, incongruity of management protocols, and the imprecise reporting of outcomes were limiting factors in the comparability of the results, leading to heterogeneity in meta-analyses. Although the available evidence cannot recommend or refute the current non-surgical management, the systematic review clarifies aspects of the ongoing controversy by providing realistic estimates for non-surgical management in children with unilateral UPJO. Additionally, it reveals unclear potential risks, particularly for long-term outcomes, which were rarely reported.

PD40-04 DIAGNOSTIC ACCURACY OF URINARY β2-MICROGLOBULIN, CA19-9, NGAL AND KIM-1 IN URETEROPELVIC JUNCTION OBSTRUCTION IN ADULTS

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion III1 Apr 2016PD40-04 DIAGNOSTIC ACCURACY OF URINARY β2-MICROGLOBULIN, CA19-9, NGAL AND KIM-1 IN URETEROPELVIC JUNCTION OBSTRUCTION IN ADULTS Eduardo Miranda, José de Bessa Jr., Roberto Lopes, Victor Sougi, Hiury Andrade, Rodolfo Bandeira, Marco Arap, Anuar Mittre, Nayara Viana, Sabrina dos Reis, Katia Leite, Miguel Sougi, and Ricardo Duarte Eduardo MirandaEduardo Miranda More articles by this author , José de Bessa Jr.José de Bessa Jr. More articles by this author , Roberto LopesRoberto Lopes More articles by this author , Victor SougiVictor Sougi More articles by this author , Hiury AndradeHiury Andrade More articles by this author , Rodolfo BandeiraRodolfo Bandeira More articles by this author , Marco ArapMarco Arap More articles by this author , Anuar MittreAnuar Mittre More articles by this author , Nayara VianaNayara Viana More articles by this author , Sabrina dos ReisSabrina dos Reis More articles by this author , Katia LeiteKatia Leite More articles by this author , Miguel SougiMiguel Sougi More articles by this author , and Ricardo DuarteRicardo Duarte More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1536AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteropelvic junction obstruction (UPJO) causes urinary tract obstruction and can lead to progressive deterioration of renal function. In this context the development of novel methods capable of discriminating obstruction and hydronephrosis may be useful. The aim of this study was to evaluate the diagnostic accuracy properties of four urinary biomarkers in adults with UPJO: β2-microglobulin (β2M), CA19-9, NGAL and KIM-1. It was also our goal to assess the behavior of these urinary biomarkers following pyeloplasty. METHODS We prospectively studied patients aged >18 years diagnosed with UPJO undergoing laparoscopic pyeloplasty from December 2013 to February 2015. We excluded patients with bilateral UPJO, unilateral UPJO and contralateral pathologic kidney, solitary kidney, history of previous treatment for UPJO, and renal insufficiency. Each patient provided four samples of voided urine for biomarker measurement, one at preoperative consultation and the others at 1, 3 and 6 months of postoperative follow-up. A control group was selected among healthy individuals with no hydronephrosis on ultrasound evaluation. RESULTS We included 47 patients with a mean age of 38.6 ± 12.7 years (range 19-64 years), from which 17 (36.2%) were males and 30 (62.8%) were females. The control group consisted of 44 subjects aged 38.3 ± 13.0 years, 14 (31.8%) men and 30 (68.2%) women. The groups were similar regarding age (p = 0.95) and gender (p = 0.82). β2M had an area under the curve (AUC) of 0.61 (95% CI 0.50-0.73) and was the only biomarker with inadequate properties in this scenario. CA19-9 had an AUC of 0.70 (95% CI 0.60-0.81), NGAL 0.71 (95% CI 0.61-0.83) and KIM-1 0.79 (95% CI 0.70-0.89). These 3 biomarkers showed similar diagnostic properties, in which KIM-1 was the most sensitive marker with a cutoff of 170.0 pg/mg creatinine (sensitivity 91.4%, specificity 59.1%) and CA 19-9 as the most specific one, displaying a cutoff of 50.0 U/mg creatinine (sensitivity 48.9%, specificity 88.0%). After pyeloplasty, there was a significant decrease in biomarkers concentrations, reaching levels similar to controls. CONCLUSIONS The evaluation of urinary biomarkers is useful in the assessment of UPJO in adults undergoing laparoscopic pyeloplasty. Urinary concentrations of CA 19-9, NGAL and KIM-1 were elevated in patients with UPJO and significantly decreased after pyeloplasty. The exact role of those biomarkers in the setting of obstruction in adults should be further evaluated. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e936-e937 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Eduardo Miranda More articles by this author José de Bessa Jr. More articles by this author Roberto Lopes More articles by this author Victor Sougi More articles by this author Hiury Andrade More articles by this author Rodolfo Bandeira More articles by this author Marco Arap More articles by this author Anuar Mittre More articles by this author Nayara Viana More articles by this author Sabrina dos Reis More articles by this author Katia Leite More articles by this author Miguel Sougi More articles by this author Ricardo Duarte More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Presentation, Management and Long-Term Outcome of Ureteropelvic Junction Obstruction in Duplex Kidneys

Ureteropelvic junction obstruction in association with a duplex collecting system is a rare but challenging upper urinary tract pathology. We report our 21-year experience with this anomaly in terms of presentation, diagnostic evaluation and management. We retrospectively identified all patients with ureteropelvic junction obstruction in a duplex collecting system between 1991 and 2012. We reviewed each case for presenting symptoms, anatomy and management. Median followup was 10.8 years (range 2 to 22). Ureteropelvic junction obstruction in duplex kidneys was diagnosed in 21 patients. Ten patients presented with clinical symptoms such as flank pain and urinary tract infection but 11 were asymptomatic. Six patients were diagnosed by prenatal ultrasound. The lower pole and the upper pole were affected in 22 and 3 renal units, respectively. Bilateral ureteropelvic junction obstruction was found in 4 cases. Duplication was complete in 5 patients, incomplete in 11 and undetermined in 5. Surgery was performed in 14 patients, including pyelopyelostomy or ureteropyelostomy in 7, dismembered pyeloplasty in 6 and heminephrectomy in 1. Reintervention was required in 1 case. Conservative treatment was adopted in 7 patients with clinically insignificant obstruction and unimpaired renal function. In all of these patients upper urinary tract dilatation gradually improved during 3 years. Ureteropelvic junction obstruction in a duplex kidney is a rare but challenging anomaly that requires careful evaluation. Treatment should be individualized according to clinical presentation (symptomatic/asymptomatic), anatomy (lower/upper pole), duplication type (complete/incomplete) and obstruction with time (severity/development) on dynamic renogram.

Stentless pyeloplasty for ureteropelvic junction obstruction in children

Introduction Stenting after pyeloplasty is an established practice and helps in ensuring a patent anastomosis until healing has completed. Stents, however, may cause complications such as infection and displacement and increase the cost of management; therefore, stentless pyeloplasty is now considered as feasible alternative. Patients and methods From August 2008 to October 2010, we retrospectively analyzed the results of stentless surgery in patients with ureteropelvic junction (UPJ) obstruction. In all, 42 patients with UPJ obstruction were managed. Nine patients who were treated conservatively, one who underwent nephrectomy, and one pyelostomy for pyonephrosis in solitary kidney were excluded. Age range at surgery was 14 days–12 years with a mean age of 12.7 months. Results There were 23 male patients and eight female patients with a male-to-female ratio of 3 : 1. Fourteen patients had left, 12 right, and five had bilateral UPJ obstruction. A total of 34 pyeloplasties were performed in 31 patients. Of the five patients with bilateral UPJ obstruction, three underwent bilateral pyeloplasty and remaining two underwent unilateral pyeloplasty with conservative management on the opposite sides. Two patients underwent laparoscopic pyeloplasties and 32 pyeloplasties by open technique. Double J stent was placed at initial surgery in three patients and 31 stentless pyeloplasties were performed. The mean operative time was 75 min. The mean perinephric drain removal time was 2 days. None of the patients had persistent urinary leak. The mean hospital stay was 3.2 days. Reduction in anteroposterior diameter was noticed in 91% cases on 12 weeks follow-up scan. Complications included persistent or increase in hydronephrosis in three (9%) patients. In all the three patients, cystoscopic stenting was attempted. In two patients, size 4 Fr double J stent was passed easily into the renal pelvis. One patient improved, whereas other still has a dilated pelvis with static anteroposterior diameter after removal of stent at 6 weeks; patient is kept on close surveillance on regular ultrasonography. Re-exploration was performed in one patient, which showed kinking at the anastomosis site. Pyeloplasty was revised and patient improved. Other complications included lumbar hernia in one patient, which improved at 6-month follow-up, and stitch granuloma in one patient, which improved after removal of residual stitch. Conclusion Stentless surgery for UPJ obstruction is a safe and feasible technique; it reduces the cost of surgery and avoids multiple procedures. Keywords : management, pyeloplasty, stentless, ureteropelvic junction obstruction

Long-Term Results of Anderson-Hynes Pyeloplasty in Children: How Long Follow-Up Is Necessary?

After a successful pyeloplasty at 3 to 6 months, the question remains whether children need a long follow-up. The medical charts of patients with long-term follow-up (> 5 years), who underwent dismembered pyeloplasty for uretero-pelvic junction obstruction (UPJO) from May 1998 to May 2007, excluding those with bilateral UPJO, solitary kidney, associated vesicoureteral reflux or other abnormalities, and inconclusive renogram due to poor renal function, were retrospectively reviewed. Ultrasonography, differential renal function (DRF, DMSA), and renal drainage on diuretic renography (diethylene-triamine-pentaacetate technetium-99 or DTPA-Tc99) were performed at 3 and 6 months every year. Complete data were available for 28 consecutive patients (28 renal unities) with 2 months to 12 years (mean age, 2.4 years) at surgery, of whom 21 (75%) were boys, 17 diagnosed prenatally (61%) and 18 unities (64.3%) were left, with median follow-up of 10.7 years. Images were graded according to the Society for Fetal Urology grading system: Grade III in 11 (49%) and grade IV in 17 (61%). All cases presented > 10% DRF (DMSA) and obstructed DTPA-Tc99. The T1/2 (the half-time of drainage) less than 20 minutes at 3 months was found in 21 cases (75%) and less than 25 minutes in 7 cases (25%). Renal function and patency were maintained during follow-up for all units with 8% maximum fluctuation of DRF. One index case (3.6%) of renal function deterioration presented DRF fluctuation > 8% at 3 months (from 23 to 32%) and progressive hydronephrosis and indeterminate DTPA at 6 months. Satisfactory diuretic renogram at 3 to 6 months after pyeloplasty with maintained renal function and stable hydronephrosis suggests no need for further follow-up and indicates no functional loss with time. More than 8% DRF fluctuation might be a significant cutoff for further intervention aiming nephron preservation.

Factors Indicating Renal Injury in Pediatric Bilateral Ureteropelvic-junction Obstruction

To analyze the factors indicating renal injury in patients with bilateral ureteropelvic-junction obstruction (UPJO). We investigated 26 patients, 35 kidney units (KUs), who were diagnosed with bilateral UPJO and underwent unilateral or bilateral pyeloplasty between January 2000 and December 2011. During pyeloplasty, ipsilateral kidney biopsy was performed. Kidney biopsy results were divided into 3 categories. Hydronephrosis was analyzed using both the Society of Fetal Urology (SFU) and Onen's grading system. We investigated factors related with the renal histopathologic results of 29 KUs. We additionally analyzed whether there were factors predicting contralateral pyeloplasty after initial unilateral pyeloplasty. Ten KUs (34.5%) showed grade 1 histopathologic change, whereas 10 KUs (34.5%) and 9 KUs (31.0%) showed grade 2 and 3 change, respectively. Preoperative differential renal function (DRF) and serum creatinine levels were not different among groups (P= .697 and .516, respectively). Hydronephrosis grade was not different when graded by SFU system (P= .100) while significantly different by Onen's system (P<.001). Among 23 patients with initial unilateral pyeloplasty, additional contralateral pyeloplasty was required in 6 patients (26.1%). There were no significant preoperative factors predicting the need for additional operations. In bilateral UPJO, DRF, and SFU grade of hydronephrosis did not correctly reflect renal injury. Onen's hydronephrosis grade showed a significant relationship with renal histopathologic grade and could be an indicator for renal injury in bilateral UPJO.