Diagnosis Of Pelvi-ureteric Junction Obstruction Research Articles

Laparoscopic Pyeloplasty in Paediatric Age Group with Standard Adult Sized Laparoscopic Instruments

Most paediatric patients attend Urology Outpatient Department with diagnosis of pelviureteric junction obstruction. Now-a-days laparoscopic pyeloplasty is increasingly been used for the pelviureteric junction obstruction in paediatric patients. In the present case series, four paediatric patients of pelviureteric junction obstruction with age group of six, seven, eight and 12 years underwent laparoscopic pyeloplasty with adult sized laparoscopic instruments with ports size of 5 mm and 10 mm. Outcomes were measured in terms of mean operative duration, mean hospital stay and complications and improvement in Glomerular Filtration Rate (GFR). Mean operative duration was 211 min , mean blood loss of 96.25 mL and mean hospital stay was 5.75 days. Mean preoperative and mean postoperative GFR (at three months) were 53.19 mL/min and 55.35 mL/min respectively. In postoperative period one patient had increased drain output of more than 250 mL up to postoperative day three. All four patients had minor complications like postoperative fever on postoperative and ileus which were managed conservatively. Mean postoperative follow up duration was six weeks when Double-J (DJ) stent was removed. All patients had good outcome in terms of being asymptomatic and decreased hydronephrosis on follow-up renal ultrasonography and increased function of operated kidney on renal scan at three months. Based on intraoperative and postoperative observations, adult sized laparoscopic instruments can be used with ease with changes in port position and length of instrument inserted , adult sized laparoscopic instruments can be a useful armamentarium for paediatric laparoscopic pyeloplasty in cases of unavailability or intraoperative instrumental damage.

Robot-assisted laparoscopic pyeloplasty: A retrospective case series review.

Introduction:Anderson-Hynes pyeloplasty has been gold standard in the management of pelviureteric junction obstruction (PUJO). It has evolved from open to laparoscopic and now robotic surgery. Open surgery has its drawback of long incision and scar mark, significant post-operative pain and long hospital stay. The main limitation of laparoscopic surgery had been the difficulty in endosuturing. Robotic surgery has incorporated the minimal access method of laparoscopy and endowrist movement of open surgery to overcome the challenge of intracorporeal suturing. Here, we present our initial experience of robotic pyeloplasty.Patients and Methods:A total of 30 patients underwent robot-assisted laparoscopic pyeloplasty (RALP) over 19 months. Diagnosis of PUJO was made by computed tomography urography, diuretic renogram and retrograde pyelogram in selected patients. All patients underwent RALP by colon reflecting approach. Post-operative evaluation was done by DTPA scan at 3- and 6-month follow-up. Data were analysed after a mean follow-up of 11 months.Results:The mean operative time was 148 min and the mean hospital stay was 3.5 days. While 93% of the patients showed objective improvement in their drainage pattern on DTPA renogram, 90% of the patients were symptom-free at the end of 6 months.Conclusions:Robotic pyeloplasty is a safe and easily conquerable technique with comparable outcomes in the hands of surgeons who are beginners in this technique.

Antenatal Diagnosis of Pelvi-ureteric Junction Obstruction & its Outcome

Antenatal Diagnosis of Pelvi-ureteric Junction Obstruction & its Outcome

Resource Utilization and Costs Associated with the Diagnostic Evaluation of Nonrefluxing Primary Hydronephrosis in Infants

Long-term evaluation of postnatal nonrefluxing primary hydronephrosis presents a dilemma for urologists since most cases resolve without surgery. We report longitudinal resource utilization and costs associated with diagnostic evaluation of infants with isolated primary nonrefluxing hydronephrosis to determine the costs associated with diagnosing a surgical case, and we assess the implications using a cost-consequences analysis. A retrospective chart review was used to capture resource utilization for all patients younger than 6 months with hydronephrosis evaluated at our institution during a 5-year period. Infants with confounding urological diagnoses were excluded. Payer and societal perspectives were used. Costs were estimated from resource utilization, including radiographic imaging and clinical encounter types. Data were collected from first clinic visit until surgery or resolution or 3 years, whichever was shortest. Of 165 included patients surgical rates for hydronephrosis were 0% forgrade I, 5% for grade II, 21% for grade III and 74% for grade IV. Median respective costs of identifying a single surgical case per increasing hydronephrosis grade 0 to IV were infinite, $37,600, $11,741 and $2,124 (p <0.001), respectively. Diagnostic evaluation of higher grades of hydronephrosis is significantly more productive in terms of identifying patients requiring surgery vs evaluation of patients with lower grade disease. In patients with grades I and II hydronephrosis a more abbreviated diagnostic strategy than the current standard of care may be warranted. For the population in this analysis we project that a less intensive approach could save about 24% of costs.

Laparoscopic pyeloplasty for Children with pelvic ure- teric junction obstruction: An institutional experience

To give a report of 36 consecutive children who underwent laparoscopic Anderson-Hynes dismembered pyeloplasty by a single lead surgeon.The diagnosis of pelviureteric junction obstruction was firmly established in all patients based on history, clinical examination, renal sonography and scintigraphy. Transperitoneal laparoscopic Anderson-Hynes pyeloplasty was performed in all the patients. Age at surgery, duration of operation, complications and outcome were documented. Children were followed up for symptoms, and diuretics renography was repeated at 3 months.A total of 36 children 5 months to 11 years (25 boys and 11 girls) under- went laparoscopic Anderson- Hynes pyeloplasty over a 4- year period. Mean age at surgery was 41 months (range 7 to 144). Seventeen (47%) cases were antenatally diagnosed. The mean operating time was 247 min. No patient required blood transfusion, and there were no intra-operative complications. The mean postoperative hospital stay was 5.8 days. There were 7 postoperative complications including urinary tract infection (n=6) and shoulder pain (n=1). The symptoms improved in 32(89%) children. There were 3 conversions, 2 due to non rotated kidney and one due to double right moiety. One child had failed pyeloplasty with deteriorating renal function. He had a redo open pyeloplasty. The mean split renal function before surgery and at follow up diuretic scan was 36.2 vs 42.1, P=0.001. The mean follow up period was 30 months.Laparoscopic Anderson-Hynes pyeloplasty is safe and effective in the management of children with pelvi-ureteric junction obstruction.

Radiological finding in pediatric patients with urinary tract infections

Background; determining what radiologic studies to obtain following the diagnosis of a urinary tract infection(uti) is an area of medicine that is still not agreed upon, nor is there a gold standard.Objective; to study the radiological abnormalities in paediatric patients with urinary tract infections.Patients and methods; this prospective study was done from the first of june 2008 to the first of may 2009 include 104 pediatric patients who were referred to children welfare hospital ,(pediatric nephrological out patient clinic) with signs and symptoms of urinary tract infections, all of them had culture positive urine examination , ultrasonograhy was done for all patients, voiding cystouretherography was done for patients with recurrent attacks of urinary tracts infections (58 patients),and intravenous urography was done for patients with urinary tract abnormalities on ultrasonography (41patients).Results; the results of the present study showed that about 63( 59.4%)of infants and children with (culture positive) urinary tract infections had positive ultrasonic findings ,the most frequent ultrasonic findings was pelvicalyceal and ureteral dilatation whichwas observed in 32.6%. Thirty four(32.6% )of patients had positive findings on voiding cystography ,( grade 5&amp;4 reflux found in 22.4%). The intravenous urography study was beneficial in diagnosis of pelviureteric junction obstruction in 12.2% and visualized the obstructive effect of renal and ureteric stones in 24.4%.Conclusion; the positive radiological findings supported the idea that the patients with recurent urinary tract infections need imaging work up.

An interesting neonatal abdominal mass

We present the case of a neonate who was born with an antenatal ultrasound diagnosis of a cystic abdominal mass of uncertain origin. The diagnosis of pelviureteric junction obstruction (PUJO) was obscured by difficulty determining the origin of the extremely large cystic abdominal mass. Sonographically, the kidneys appeared relatively normal, creating a diagnostic dilemma — the hydronephrosis was almost exclusively in an extrarenal pelvis. Additionally, contralateral hydronephrosis secondary to the mass effect further confused the diagnosis. We discuss the differential diagnosis of neonatal cystic abdominal masses and review the literature of giant hydronephrosis.

Does Renal Function Remain Stable After Puberty in Children With Prenatal Hydronephrosis and Improved Renal Function After Pyeloplasty?

We evaluated whether improved renal function after pyeloplasty for prenatal ureteropelvic junction obstruction persisted through puberty. A total of 441 males and 137 females with a prenatal diagnosis of hydronephrosis that led to the postnatal diagnosis of ureteropelvic junction obstruction were followed at our department from 1989 to 2008. Of the patients we reviewed the records of 49 who underwent surgery between 1989 and 1992, and completed puberty. Hydronephrosis was on the right side in 18 children (36.7%) and on the left side in 31 (63.3%). According to Society for Fetal Urology classification at first presentation postnatal hydronephrosis was grades 2 to 4 in 18 (36.7%), 23 (46.9%) and 8 children (16.3%), respectively. Initially relative renal function was more than 40% in 18 children (36.7%), between 30% and 40% in 24 (49%), and less than 30% in 7 (14.3%). Preoperatively mean +/- SEM relative renal function was 36.6% +/- 7.8% in all reviewed patients. Improvement in hydronephrosis was confirmed in all patients. This remained stable during and after puberty in all except 2 patients, who required endopyelotomy 8 and 10 years following pyeloplasty, respectively, due to deterioration in hydronephrosis without a decrease in relative renal function. They showed improvement in the washout curve pattern after the procedure. Pyeloplasty led to increased relative renal function in the short term from 36.7% +/- 1.2% before surgery to 41.2% +/- 0.91% in all patients (p <0.001). It remained stable at 43.2% +/- 0.75% after puberty in all reviewed patients. To our knowledge our data show for the first time that successful pyeloplasty after the prenatal diagnosis of ureteropelvic junction obstruction is associated with improved renal function throughout puberty.

How successful is the conservative management of pelvi‐ureteric junction obstruction in adults?

To assess the conservative management of pelvi-ureteric junction obstruction (PUJO), according to severity, accepted in paediatric urology but rarely reported in adults. A series of 23 patients (median age 58 years, 17 men and six women) with asymptomatic or minimally symptomatic PUJO were managed conservatively. The patients' age, preference and comorbidities were considered. The diagnosis of PUJO was based on intravenous urography and isotopic renography. After stringently reviewing the renograms based on relative renal function (RRF) and output efficiency (OE), 15 patients had an OE consistent with definitive PUJO. One patient had no further imaging due to associated comorbidities. Ten patients had right PUJO, three left and one with bilateral PUJO, with unilateral conservative management. The follow-up included annual renography and clinical consultation. Laparoscopic pyeloplasty was considered for patients with a >10% loss of RRF and/or <40% RRF during the follow-up. Overall, 14 of 15 patients had renograms during the follow-up. The mean RRF of the affected kidney at diagnosis was 48.6% which marginally decreased to 46.7% after a median (range) follow-up of 44 (23-75) months. The RRF of 11 patients remained stable and in three decreased significantly (median 11% RRF), requiring pyeloplasty. None of the patients became symptomatic throughout the follow-up. In asymptomatic adults the conservative management of PUJO appears to be safe during a short- to medium-term follow-up. We recommend that patients are regularly followed with renography and seen promptly should they become symptomatic. A longer follow-up is needed in a larger group to confirm these findings.

Retroperitoneal dismembered pyeloplasty: Initial experiences

To review the results of our first 40 cases of retroperitoneal dismembered pyeloplasty and to compare them with series of open and other minimally invasive treatments of pelviureteric junction (PUJ) obstruction. Also to compare our first 20 cases with the second 20 cases to see if there was an improvement in results with experience. A retrospective review of the first 40 laparoscopic pyeloplasties performed by a single lead surgeon at two institutions was performed. The diagnosis of PUJ obstruction was confirmed with an intravenous urogram as well as a renogram prior to surgery. A retroperitoneal, dismembered pyeloplasty was routinely performed with three or four ports. All patients were followed up with an intravenous urogram, renogram and review of symptoms at 4 months and annual renogram after that. Average operation time was 236 min and this appeared to decrease with experience. Two cases had to be converted to open operations. The mean hospital stay was 3.4 days. Out of the 40 patients, 34 have had successful laparoscopic operations with total symptomatic relief as well as radiologically proven deobstruction. There were four major complications with 3 patients going on to have redo open pyeloplasty operations. There were seven minor complications. In our experience, retroperitoneal dismembered pyeloplasty is an effective and safe means of treating PUJ obstruction. Our results seem to be comparable with series of open pyeloplasty and other laparoscopic series and are better than some other minimally invasive techniques.

Magnetic Resonance Urographic Parameters for Predicting the Need for Pyeloplasty in Infants With Prenatally Diagnosed Severe Hydronephrosis

Treatment in infants with prenatally diagnosed, severe hydronephrosis remains controversial. We measured anatomical parameters using magnetic resonance urography to create a pelvic index ratio, which we correlated with outcome to assess its value. We reviewed 35 cases of prenatally diagnosed severe hydronephrosis, including grade III in 19 and grade IV in 16. By 6 weeks after birth all patients had undergone repeat ultrasonography, diuretic renography and magnetic resonance urography. Magnetic resonance urography was used to measure the distance (D) from the bottom of the lowest renal calyx to the ureteropelvic junction and the total longitudinal length (L) of the caliceal system. The pelvic index ratio, defined as D/L, assesses the level at which the ureter inserts into the renal pelvis. All cases were initially managed conservatively. Pyeloplasty was required in 16 kidneys (mean patient age +/- SD 7.5 +/- 3.9 months) because of deterioration in renal function. All patients were well at a mean followup of 3.8 years. The remaining 19 cases continued to be managed conservatively. By a mean of 5.4 years spontaneous resolution of prenatally diagnosed severe hydronephrosis had occurred in 7 of 19 cases, while 12 were downgraded to grades I-II. The mean pelvic index ratio in surgical cases was 0.26 +/- 0.13 and in nonsurgical cases it was 0.12 +/- 0.11, indicating that ureters inserted significantly higher in surgical cases (p = 0.0012). Of 9 kidneys with a pelvic index ratio of greater than 0.3 pyeloplasty was required in 8, while 10 of 12 with a pelvic index ratio of less than 0.1 were managed conservatively. Pyeloplasty is likely to be required if the pelvic index ratio is greater than 0.3 and conservative management is likely to succeed if the ratio is less than 0.1. The pelvic index ratio can be calculated easily even in the neonatal period. It appears to be prognostic for pyeloplasty in cases of prenatally diagnosed, severe hydronephrosis.

Does delaying pyeloplasty affect renal function in children with a prenatal diagnosis of pelvi-ureteric junction obstruction: B. Chertin, U. Rolle, A. Farkas, et al. Br J Urol Int 90:72–75, (July), 2002

Does delaying pyeloplasty affect renal function in children with a prenatal diagnosis of pelvi-ureteric junction obstruction: B. Chertin, U. Rolle, A. Farkas, et al. Br J Urol Int 90:72–75, (July), 2002

Vesico-ureteric reflux and surgically treated pelvi-ureteric junction obstruction in infants under the age of 12 months.

Pelvi-ureteric junction obstruction has been increasingly diagnosed in infants, mostly as a consequence of antenatal ultrasound examinations. Of 55 infants below the age of 12 months who underwent dismembered pyeloplasty over a 7-year period, we aimed to determine the patterns and outcome of associated vesico-ureteric reflux that was present in 15 (28%) of the 53 infants in whom follow-up was available. A total of eight infants had resolution of their reflux with conservative management and the median time to resolution was 15 months. Five infants proceeded to ureteroneocystotomy. Given the association of vesico-ureteric reflux and pelvi-ureteric junction obstruction, routine cystography is recommended when the diagnosis of pelvi-ureteric junction obstruction is made.

Frusemide intravenous urography in the diagnosis of pelviureteric junction obstruction.

Standard intravenous urography is not a reliable method of demonstrating pelviureteric junction obstruction. Frusemide urography enables 3 groups to be defined on the basis of the percentage increase in the size of the renal pelvis after the diuretic. These groups are clinically significant.

The echography of pelvi-ureteric junction obstruction in children

The echographic appearances seen in 47 children with dilatation of the pelvi-calyceal system but not ureter, in whom the diagnosis of pelvi-ureteric junction obstruction was strong enough to lead to surgical correction, were classed into two categories. Those children in whom the antero-posterior diameter of the pelvi-calyceal system exceeded 10 mm were classed as being 'suspicious' (of pelvi-ureteric junction obstruction). When dilatation of the pelvis was accompanied by dilatation of the calyces this appearance was classed as 'definite'. There was a high false positive rate but a very low false negative rate. A simple water load stress test performed in 17 children helped to decrease the false positives from 16 to 10 but the high false positive rate in the 'definite' group stresses the need for subsequent functional studies. Ultrasound is concluded to be a worthwhile screening test to select children requiring functional studies.

Renal scintigraphy: Quantitative assessment of upper urinary tract dilatation in children

A standard method of Tc-DTPA renal scintigraphy has been used to examine 426 dilated upper urinary tracts in children aged 2 days-16 yr. The method provides an accurate estimate of individual kidney function and defines the extent of dilatation. Renogram analysis and frusemide-induced diuresis have been applied in an attempt to distinguish between the obstructed upper tract and the dilated upper tract without obstruction. In 304 upper tracts, obstruction was predicted with an overall sensitivity of 0.87. The sensitivity for diagnosis of pelviureteric junction obstruction was 0.93. The value of scintigraphy in excluding significant obstruction and in follow-up studies is emphasized. This is a noninvasive, low-radiation investigation which plays an important role in the assessment of obstructive uropathy in childhood and represents a major advance in diagnostic facilities.