Diuretic Renogram Research Articles

Laparoscopic Pyeloplasty with Intracorporeal Flexible Ureteroscopy: A Management Option for Pelviureteric Junction Obstruction and Multiple Caliceal Calculi

Introduction: Laparoscopic pyeloplasty (LP) is a well-accepted minimally invasive approach for the management of pelviureteric junction obstruction (UPJO).1 In patients presenting with UPJO and multiple calculi, calculi located in renal pelvis can be cleared following pyelotomy during LP. However, multiple caliceal calculi are difficult to extract by pyelotomy alone. Usage of intracorporeal flexible ureteroscopy (IFURS) for clearance of caliceal calculi during laparoscopic pyelolithotomy for large staghorn calculus has been previously described.2 We present a video demonstration of LP and IFURS for simultaneous addressal of UPJO and multiple caliceal calculi. Materials and Methods: Preoperative assessment included present history, clinical and biochemical profiles, and imaging (radiography [XR], ultrasound [USG], computed tomography urogram [CTU], diuretic renogram [DR], and retrograde pyelogram [RGP]). Patients with significant UPJO and multiple caliceal calculi comprised the study cohort. All procedures were conducted through transperitoneal access. After dismemberment of pathological segment and pyelotomy, FURS with access sheath was inserted through a 5-mm working port and directed into the pelvicaliceal system under direct supervision. Flexible ureteroscopy was then carried out, all calices inspected, and caliceal calculi were retrieved using entrapment basket. The retrieved calculi were immediately transferred to the intraperitoneal retrieval bag. Pyeloplasty was then completed, pelviureteric approximation with interrupted sutures and pelvic edge approximation in continuous manner. Ureteral stent was placed in an antegrade manner. Operative and postoperative parameters were noted. Stent removal was undertaken at 6 weeks. Follow-up assessment included USG and XR for calculi clearance. Drainage was assessed by RGP and DR at 6 months postoperatively. Results: Between July 2012 and January 2013, five similar procedures were conducted. The mean age was 32.2 years (range, 8–55 years). The mean number of caliceal calculi was 18.8 (range, 5–59). Pathology involved the left side in four and the right side in one. One unit was malrotated. The mean preoperative glomerular filtration rate (GFR) was 30.2 mL/minute (range, 22.2–34.8 mL/minute). The mean operative duration was 280 minutes (range, 240–330 minutes). The mean blood loss was 75 mL (range, 50–100 mL). No major intraoperative or postoperative events were noted. The mean hospital stay was 3.8 days (range, 3–5 days). Complete clearance of calculi at pyeloplasty was possible in four patients (80%). One patient required additional flexible ureteroscopy during stent removal. Till last follow-up, all patients were symptom free. The mean 6-month postoperative GFR was 42.2 mL/minute (range, 40.4–44.6 mL/minute) (p < 0.001). Conclusion: Intracorporeal usage of FURS during LP enables simultaneous addressal of multiple caliceal calculi and UPJO, preserving the goals of minimally invasive access. The procedure is well tolerated and renders satisfactory outcome. No competing financial interests exist. Runtime of video: 7 mins 51 secs

Postnatal Behavior and Outcome of Antenatally Detected Hydronephrosis and Predictors for Surgical Intervention

Objective: To observe the postnatal behavior and outcome of antenatally detected hydronephrosis due to UPJ obstruction and to determine the predictors for surgical intervention. Study Design: Prospective, observational, descriptive study. Subjects: 24 babies with 33 renal units with hydronephrosis due to UPJ obstruction detected antenatally. Methodology: Hydronephrosis grading was done according to SFU grading. All patients were initially treated non-operatively regardless of the initial degree of hydronephrosis, differential function, or diuretic renogram and followed up until either there was objective evidence that the hydronephrosis improved or obstruction existed. Results: Of the 24 neonates with 33 renal units majority were males and 38% had bilateral hydronephrosis. 58% hydronephrotic units improved and 42% required pyeloplasty later on but none required nephrectomy. None of SFU Grade-I, 37% patients of SFU Grade-II, 47% patients of SFU Grade-III and all patients of SFU Grade-IV underwent surgery. Presence of sign/symptoms, obstructive curve and deterioration in differential function and paradoxical hyper functioning indicate the need for surgery. Conclusion: Postnatal outcome can be predicted from antenatal SFU Grade of hydronephrosis; as the grade increases future chances of surgical intervention increase.

Prompt Management of Anastomotic Leak or Acute Obstruction after Minimally Invasive Pyeloplasty with Percutaneous Nephrostomy Preserves Outcomes

Urine leak or obstruction in the early postoperative period is a worrisome complication of pyeloplasty. Suboptimal management may risk long-term success. We evaluated percutaneous nephrostomy to manage complications of minimally invasive pyeloplasty. We retrospectively analyzed the records of 125 patients who underwent minimally invasive pyeloplasty performed by a single surgeon from May 2004 to May 2013. All complications were catalogued and patients with anastomotic urine leakage or postoperative obstruction were identified. Less than 7 days postoperatively percutaneous nephrostomy was done in each case. Surgical success was defined as resolution of flank pain and/or improved half-time (less than 20 minutes) on diuretic renogram. Early percutaneous nephrostomy placement was required in 12 patients (9.6%) for symptomatic obstruction (6) or anastomotic urine leakage (6) a median of 4.5 days (range 2 to 7) postoperatively. Percutaneous nephrostomies remained in place a median of 9.5 days (range 5 to 42). Median followup was 15 months (range 2 to 80). Mean half-time was 36.4 minutes preoperatively and 11.1 minutes postoperatively. Continued postoperative obstruction (half-time greater than 20 minutes) was documented in 1 (8%) and 13 patients (11.5%) who did and did not require percutaneous nephrostomy placement, respectively. There was no statistical difference in radiological and clinical success rates between the percutaneous nephrostomy group and the 113 patients in whom minimally invasive pyeloplasty was uncomplicated (p = 0.74 and 0.28, respectively). In patients treated with minimally invasive pyeloplasty aggressive management of acute urinary complications with percutaneous nephrostomy placement preserved radiographic and symptomatic outcomes that were comparable to those in patients without complications.

Trends in Followup Imaging after Adult Pyeloplasty

Although success rates are reported to be high, radiographic followup after pyeloplasty to correct ureteropelvic junction obstruction varies in intensity and modality. We characterized postoperative care after pyeloplasty to identify imaging trends. Using the MarketScan® database we identified patients 17 to 65 years old treated with pyeloplasty from 2007 to 2010. Followup imaging was classified as functional (diuretic renogram or excretory urogram) and nonfunctional (ultrasound, computerized tomography or magnetic resonance imaging). The postoperative period was divided into intervals of less than 6, 6 to 12, 12 to 24, 24 to 36 and greater than 36 months. We excluded from study patients with less than 24 months of postoperative enrollment in MarketScan. Multivariate logistic regression was used to determine associations between demographic variables and imaging utilization patterns. We identified 742 patients with a mean ± SD followup of 36.8 ± 3.7 months, of whom 65% underwent minimally invasive pyeloplasty. Of the patients 12% underwent no postoperative imaging. Within the first 6 months 554 patients (75%) underwent at least 1 imaging study and within the first 12 months 82% underwent at least 1 imaging study, which was most commonly functional. After 12 months 54% of patients underwent any imaging, which was most commonly nonfunctional. At least annual imaging was significantly associated with older age, female gender and longer hospital stay. Secondary procedures were required in 62 patients (8%). After pyeloplasty in adulthood most patients undergo a functional imaging study within 6 months. However, after 1 year only half of patients undergo followup imaging. Variability and insufficient radiological followup may bias the belief of pyeloplasty success.

Postoperative evaluation of hydronephrosis due to the way of pyeloplasy (dismembered / non-dismembered).

Central European Journal of Urology106Cent European J Urol 2014; 67: 106-107 10.5173/ceju.2014.01.art25In recent years, we have seen rapid development of minimally invasive procedures in urologic oncology, but also in corrective surgery of congenital defects, including ureteropelvic junction obstruction (UPJO). After a period of testing the endoscopic treatment of UPJO, currently the majority of patients undergo laparoscopic or robotic surgery. Recently, single port laparoscopy (LESS) has become an optional technique in the urological armamentarium. Laparoscopic treat -ment of UPJO in adults has been established as the “gold standard” means of curing this quite common disease. Nowadays it draws much attention as it is one of the very few urological laparoscopic operations that can be done relatively easily by a laparoscopist with limited experience, and as such, resembles the case of cholecystectomy for general surgeons [1, 2]. Abundant literature offers much data about very good postoperative functional results of laparascopy: equal to open surgery and with the known advantage of min -imal invasiveness. In contrast, many authors contin-ue to commission research of functional supervision of patients after UPJO repair, since the disappearance of hydronephrosis observed in the ultrasound over a longer period of time may also result from the deterio -ration of renal function. However, it is surprising that the authors very seldomly give precise details about how long after the procedure the final outcome was evaluated and which diagnostic tools should be used. In the current issue of CEJU, Isoyama and co-oper-ators present a very interesting paper inspired by data coming from paediatric surgeons that the hy-dronephrosis after UPJO repair may subside very gradually, probably as the elastic properties of the renal pelvis may differ individually. According to the authors, this has two practical consequences. Firstly, provided that there are no remaining symptoms , the judgement of the result of surgery should be post-poned, as there is still time for improvement, even as long as two years after the operation. Secondly, serial ultrasound may be a valuable alternative to more invasive diagnostic tests, such as intravenous pyelography (IVP) or diuretic renogram, during the follow-up. It is worth noting that, in our opinion, the evaluation of the hydronephrosis stage changes should be sought for each patient individually, as a step in the laparoscopic partial resection of the en-larged renal pelvis. In some cases immediately af-ter surgery, with radical removal of the excess renal pelvis, the hydronephrosis is no longer observed [3]. The ultrasound evaluation of the functional effect of the surgery, by reducing the hydronephrosis, seems to be useful in the case of non-dismembered pyelo-plasy, since the treatment is limited only to the lon-gitudinal cut of UPJO and transverse suture without resection of the stenosed part of the renal pelvis [4].The study is small as it is based on the analysis of only 16 patients, but may give urologists some scientific sup-port for consultation of patients after UPJO surgery, who do not have symptoms, but are uncertain about the outcome, especially if there is some persistent hydro-nephrosis. From the Isoyama paper, we may conclude that the resolution of hydronephrosis may take even two years and may be followed very well by measure-ments from subsequent ultrasound evaluations, which are better that USG tests done separately. It can spare the patient unnecessary tests or maybe sometimes even prevent an unnecessary re-do operation. More-over, subsequent ultrasound measurements of the size of the renal pelvis in the improvement of kidney func-tion, after dismembered pyeloplasty of UPJO, in our opinion, provide an interesting noninvasive diagnostic option, but should be carried out individually, taking into account the extent of renal pelvis resection during surgery for each patient. If there are still any doubt as to the effect of the treatment, diuretic renogram and IVP remain the standard diagnostic procedures.Editorial referring to the paper published in this issue on pp. 101–105

Evaluation in children of the standard diuretic renogram with furosemide at 20min, as compared to the diuretic renogram with furosemide after 2min

Purpose: The aims of this study in children were a) to compare the renogram with furosemide at 20min (F+20) with the renogram obtained by injecting furosemide after 2min (F+2) and b) to define the normal values of parameters for the technetium-99m mercapto-acetyl-triglycine (99mTc MAG3) diuresis renography. Patients and Methods: The investigation was carried out on the sample of 77 children: 41 boys and 36 girls (median age: 26 months, age range 2-120 months) with unilateral antenatally detected hydronephrosis (HN) and contralateral normal kidney. They were divided into two groups. Group 1 consisted of 33 children who underwent standard F+20 diuresis renography, and Group 2 of 44 children with F+2 renography. Only the normal kidneys were included in the analysis. In total, 77 kidneys were analyzed. The International Atomic Energy Agency (IAEA) software package was applied to process the studies and the following parameters were analyzed: Tmax, diuresis nephrogram in children have been calculated by the means of the IAEA software. Applying these values to semi-quantitative MAG3 parameters may help in differentiation between normal and abnormal finding of diuresis renography in children. The semi-quantitative parameters facilitate the comparison between studies during follow/up and contribute to better management of children with HN.

Robotic Pyeloplasty: The Results after the First 30 Patients

The aim of this paper is to report the outcomes of 30 (first) robot-assisted pyeloplasties (RPs) performed at our institute for the treatment of ureteropelvic junction obstruction (UPJO). In the period between March 2005 and September 2012, 30 RPs due to UPJO have been performed at our institute using a three arms Da Vinci Robot, standard version. All the procedures were performed transperitoneally with Anderson-Hynes technique. 29/30 (97%) patients were affected by primary UPJO and 1/30 (3%) reported a recurrent disease. The access foresaw the positioning of three robotic trocars (one 12 mm trocar for the camera and two 8-mm trocars for the robotic arms) and one assistant 12 mm trocar. The anastomosis was confectioned on a double-J ureteral tutor with 4/0 monocryl running sutures. Outcome success was defined as resolution of preoperative symptoms and ureteropelvic junction obstruction, confirmed by the improvement of the diuretic renogram. Mean follow-up was 48.3 months (range 5-96). All procedures have been completed robotically and no conversion was needed. Mean operative times, blood losses and hospital stay were respectively 189 minutes (range 105-420), 60 mL (range 25-100) and 4.2 days (range 2-14). 29/30 patients were cured, with a success rate of 97%. As regards mild complications, 3/30 patients (10%) reported a moderate abdominal pain a few hours after surgery, which was successfully treated with common analgesic drugs. A s for major complications, one patient (3%) developed ileus, probably due to a mild urine extravasation through the ureteropelvic suture, which spontaneously disappeared three days after surgery. RP seems to be a "new gold standard" in the treatment of UPJO. The three-dimensional versatility and the outstanding accuracy of robot-assisted intracorporeal suturing produced excellent results after the first procedures without requiring a previous 'sound' laparoscopic experience.

Scintigraphy in Ochoa Syndrome

The Ochoa or urofacial syndrome is a disease characterized by non-neurogenic bladder dysfunction and unusual facial expressions when smiling or crying. It is an extremely rare disorder with over 150 cases reported in the medical literature. This condition has been determined to be inherited by an autosomal recessive pattern. We present radionuclide renogram and renal scan of a boy with a history of incontinence, frequent infections of the urinary tract, and gene mutations consistent with this syndrome. Nuclear medicine images showed extensive bilateral renal scarring and obstructive pattern in diuretic renogram.

Editorial Comment

No AccessJournal of UrologyPediatric Urology1 Sep 2013Editorial Comment Emilio Merlini Emilio MerliniEmilio Merlini More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.03.136AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 190(3), pp. 1026–1027 References 1 : The “well tempered” diuretic renogram: a standard method to examine the asymptomatic neonate with hydronephrosis or hydroureteronephrosis: A report from combined meetings of the Society for Fetal Urology and members of the Pediatric Nuclear Medicine Council–the Society of Nuclear Medicine. J Nucl Med1992; 33: 2047. Google Scholar Division of Pediatric Urology, Regina Margherita Children's Hospital, Citta della Salute a della Scienza di Torino, Turin, Italy© 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 190Issue 3September 2013Page: 1026-1027 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emilio Merlini More articles by this author Expand All Advertisement PDF downloadLoading ...

99mTc-MAG3 Diuretic Renography in Diagnosis of Obstructive Nephropathy in Adults

The objective of this study was to compare 2 diuretic renography procedures: F-15 versus F+10(sp) for diagnosis of obstructive uropathy in adults. Thirty-six patients with unilateral or bilateral hydronephrosis had 2 consecutive Tc-MAG3 diuretic renograms within 7 days, using the widely used procedure F-15 in supine position, and a new seated-position procedure whereby the patient drinks 400 to 500 mL of water at 5 minutes and receives an injection of 20 mg of furosemide at 10 minutes [F+10 (sp)]. F-15 showed nonobstructive results in 63.9% of kidneys, obstruction in 26.4%, and equivocal findings in 6.9% and was not applicable in 2.8%. F+10(sp) showed nonobstructive results in 70.9%, obstruction in 27.8%, and equivocal result in 1.4% of kidneys. Nephroptosis was observed by F+10(sp) in 22.2% of kidneys. Adverse effects reported for the F-15 were hypotension in 2 patients, renal colic in 3 patients, and interruption due to voiding in 5 patients. No adverse effects were reported for F+10(sp). This study shows that the F+10(sp) procedure reduces the equivocal findings of F-15 procedure in 36 patients. It can improve the accuracy and compliance, avoiding adverse effects and reducing bladder filling-related problems.

Laparoscopic Anderson–Hynes pyeloplasty without symphysiotomy for hydronephrosis with horseshoe kidney

The objective of this study is to clarify whether symphysiotomy is an essential procedure combined with the laparoscopic pyeloplasty for the surgical treatment of ureteropelvic junction obstruction related to horseshoe kidney. We retrospectively reviewed five horseshoe kidney patients with symptomatic hydronephrosis who underwent laparoscopic transperitoneal Anderson-Hynes pyeloplasty without symphysiotomy between July 2002 and October 2011. All procedures were completed successfully without open conversion. Mean operative time and estimated blood loss were 209 min and 40 mL, respectively. Anterior crossing vessels were observed in all cases, and four of them were defined as a principle cause of the obstruction. In the remaining case, intrinsic stenosis of the ureteropelvic junction was noted. Crossing vessels were transposed behind the ureter with ureteropelvic anastomosis at the anterior aspect of these structures. Preoperative symptoms were absent postoperatively in all cases. Diuretic renogram showed that renal function of the side with hydronephrosis was unchanged, but diuretic excretion half-time was diminished in all cases. The present data suggest that symphysiotomy can be avoided in many, if not all, cases of hydronephrosis related to horseshoe kidney. Laparoscopic Anderson-Hynes pyeloplasty with transposition of anterior crossing vessels seems effective, especially if aberrant vessels are strongly suspected to be present from the preoperative imaging examination.

Acute and delayed vesicoureteral obstruction after endoscopic treatment of primary vesicoureteral reflux with dextranomer/hyaluronic acid copolymer: Why and how to manage

ObjectiveTo present our cases of ureteral obstruction after endoscopic treatment of vesicoureteral reflux (VUR) with dextranomer/hyaluronic acid (Dx/HA). Patients and methodsWe collected data from patients who had suffered ureteral obstruction after endoscopic treatment of VUR with Dx/HA in our institution. ResultsFrom April 2002 to April 2011 we treated endoscopically 475 ureters with VUR, and detected 5 ureteral obstructions. Median age at reflux treatment was 39 months. Reflux grade before treatment was III in one patient and IV in four. Three ureterovesical junctions (UVJ) were blocked after a second endoscopic treatment. The median of Dx/HA injected was 1 ml (0.6–1.1). In two patients ureteral obstruction presented acutely and was treated with a ureteral stent. In the other three, the ureteral obstruction appeared gradually and was detected by ultrasound scans and MAG3 diuretic renogram; one underwent nephrectomy because of poor renal function, and the other two were treated with endoscopic dilatation of the UVJ. In all these patients both reflux and obstructions have resolved. ConclusionsOn preoperative cystography, three of the patients had a narrowed distal ureter, and probably had a refluxing and obstructive megaureter. Other causes are not clear, except for those patients with acute presentation in whom edema of the UVJ was found. Ureteral obstruction after endoscopic treatment of VUR is rare. Endoscopic intervention such as ureteral stent placement or high-pressure balloon dilatation of the UVJ has good results as a treatment of acute and delayed obstruction.

Renal Function After Laparoendoscopic Single Site Pyeloplasty

Outcomes after laparoendoscopic single site pyeloplasty are limited to small cohort studies with short-term followup. We evaluated the clinical and renal function outcomes of what to our knowledge is the largest laparoendoscopic single site pyeloplasty cohort to date with a mean followup of 12 months. Consecutive patients diagnosed with symptomatic ureteropelvic junction obstruction who underwent robotic or conventional laparoendoscopic single site pyeloplasty were entered into the study. Patient demographics, and preoperative and postoperative renal function outcomes were recorded. Diuretic renogram was performed after stent removal, at 6 months and yearly thereafter. The cohort included 31 conventional and 22 robotic laparoendoscopic single site pyeloplasties. Four laparoendoscopic single site surgeries (7.8%) were converted to another procedure due to failure to progress. Mean ± SD followup was 12.1 ± 10.7 months and 22 patients had at least 12 months of followup. No intraoperative complications occurred. Complications developed postoperatively in 11 patients (21%), of which 9 were Clavien grade 3 or greater. Preoperative symptoms resolved in 49 of 51 cases (96%). Severe obstruction (half-time greater than 20 minutes) was seen in 32 of 44 patients (73%) at presentation and obstruction resolved (half-time 20 minutes or less) in 41 (93%). Mean preoperative and postoperative half-time was 24.6 ± 13.4 and 8.3 ± 4.1 minutes, respectively, for an improvement of 16.3 ± 12.3 minutes (p <0.01). Laparoendoscopic single site pyeloplasty is safe and efficacious. The laparoscopic and robotic techniques provide excellent outcomes in terms of symptomatic relief and radiographic resolution of obstruction.

Robotic versus conventional laparoscopic pyeloplasty: A single surgeon concurrent cohort review

Introduction:The increasing availability of robotic devices has led to an increase in their use for procedures such as pyeloplasty, which have been conventionally performed laparoscopically or through open surgery. We perform both laparoscopic and robotic-assisted pyeloplasty routinely and have compared these techniques in a set of concurrent cohorts, operated by the same surgeon.Materials and Methods:A chart review was performed of all cases of Robot-assisted laparoscopic pyeloplasty (RALP) and conventional laparoscopic pyeloplasty (CLP) performed by a single surgeon, from September 2006 to July 2010. The choice of procedure depended upon the availability of the robot on the given day. A lateral transperitoneal approach was used in all cases. All anastomoses were stented antegrade. A diuretic renogram was obtained in all patients between six to twelve weeks after stent removal. Success was defined as a resolution of symptoms with non-obstructive outflow on the renogram.Results:Thirty patients underwent 31 laparoscopic pyeloplasties (20 RALPs and 11 CLPs), with one patient undergoing bilateral simultaneous robotic procedures. The robotic procedures were superior in terms of shorter operating time by 20 minutes on an average. Furthermore, 35% of the robotic procedures were performed in under 90 minutes, while the minimum time taken for laparoscopy was 110 minutes. All procedures in both cohorts were successful with no complications in either group. The surgeon recorded subjective ergonomic benefits with the use of the robot.Conclusions:Robotic assistance helps decrease the operative time for laparoscopic pyeloplasty. It seems ergonomically superior for the surgeon, allowing multiple procedures in the same list. These may be important benefits in busy centers.

Diagnostic Criteria for Stomal Obstruction of Tubeless Cutaneous Ureterostomy by Use of99mTc-Mercaptoacetyltriglycine Diuretic Renography

PurposeTo evaluate 99mTc-mercaptoacetyltriglycine diuretic renograms for diagnosing stomal obstruction in tubeless cutaneous ureterostomy.Materials and MethodsCutaneous ureterostomy was performed in 29 patients (56 renal units) with a minimum follow-up period of 12 months. Stomal obstruction was evaluated with 99mTc-mercaptoacetyltriglycine diuretic renography 3 months after surgery. Regions of interest were drawn that completely encircled and snugly fit the kidney, renal pelvis, and ureter. The data analyses were performed with half-times to tracer clearance following furosemide (0.5 mg/kg) administration.ResultsThe mean half-times to tracer clearance were 6.90±6.30, 5.25±4.29, and 8.75±7.63 minutes in the total, ipsilateral, and contralateral kidneys, respectively, in side relationships between the ureter and the stoma. There were significant differences between the ipsilateral and contralateral kidneys in the mean half-time to tracer clearance (p=0.038). Forty-eight renal units (85.7%) had a half-time to tracer clearance of less than 15 minutes, and all 48 renal units had no hydronephrosis. On the other hand, 5 renal units (8.9%) had a half-time to tracer clearance of more than 20 minutes, and these 5 renal units required the insertion of stent catheters or became atrophic.Conclusions99mTc-mercaptoacetyltriglycine diuretic renography was very useful for diagnosing stomal obstruction of tubeless cutaneous ureterostomy. The upper limit of the half-time to tracer clearance for unobstructed systems was 15 minutes, which allowed for the confident exclusion of stomal obstruction in tubeless cutaneous ureterostomy.

外傷性尿管狭窄に対し虫垂尿管置換術を施行した1例

We report a repair of a right ureteral stenosis with the appendix as a ureteral substitute. A 20-year-old male suffered a traumatic injury in a motorcycle accident. He underwent an emergency operation for right hemothorax, intraabdominal hemorrhage, and bone fracture of right leg. Three weeks later, right hydronephrosis and urinoma were identified. Combined retrograde and antegrade pyelography demonstrated a severe 7 cm long stenosis in the right upper ureter. After an indwelling right nephrostomy catheter was placed, he returned to the hospital for a ureteral reconstruction. We planned to substitute the appendix to bridge the stenotic ureter. After transecting the appendix from the cecum, the mesoappendix was spatulated from mesoileum. Ureteral tissue was resected and appendix was interposed. Three weeks later, ureteral stent was removed. DTPA diuretic renogram scintigraphy demonstrated no evidence of obstruction five weeks later. Two years postoperatively, the patient was asymptomatic and his renal function was normal. Although only few cases of ureteral repair with appendix are known, uretero-appandix replacement is less invasive and complicated, and recommended in some cases.

Evaluation of Differential Renal Function and Renographic Patterns in Patients with Dietl Crisis

We analyzed preoperative and postoperative differential renal function and characterized the renographic findings in patients with ureteropelvic junction obstruction associated with Dietl crisis. Patients with Dietl crisis who underwent pyeloplasty between January 2004 and December 2010 were classified by renographic presentation. Patients in group 1 were diagnosed with cortical retention, those in group 2 had an initial obstructed scan (T1/2 of 20 minutes or more and no cortical retention) and those in group 3 had an initial nondiagnostic scan (T1/2 of less than 20 minutes and no cortical retention). Renographic parameters were used to analyze each group. A total of 59 patients met criteria for study inclusion. The 13 patients in group 1 demonstrated the most significant recovery of function after pyeloplasty (mean differential renal function change 13.59%). The 38 patients in group 2 exhibited a mean differential renal function change of 43.06% (range 20% to 54.6%) and mean preoperative T1/2 of 64.31 minutes. Pyeloplasty was performed in all 8 patients in group 3 based on subsequent diagnostic scan (4 patients) or increased hydronephrosis on other imaging associated with further symptomatic episodes (4). Initial renographic patterns noted in group 3 included biphasic curves, diminished clearance after 15 minutes upright or symptoms despite nonobstructive drainage. Interpretation of diuretic renography requires the assimilation of multiple parameters since patients with Dietl crisis can exhibit variability in renographic patterns due to the intermittent nature of ureteropelvic junction obstruction. Cortical retention represents a specific and pathognomic finding of acute ureteropelvic junction obstruction. With appropriate evaluation of these parameters, obstruction can be reliably diagnosed and appropriate surgical candidates chosen.

Transperitoneal Dismembered Laparoscopic Pyeloplasty in Infants: Points of Technique

Introduction: Definitive reconstruction of pelviureteric junction obstruction has been performed by incisional, endourologic, or laparoscopic approaches.1,2 Among these, laparoscopic approach has been appraised for excellent morbidity profile and durable outcome. Contemplating laparoscopic pyeloplasty in infants poses many challenges. Apart from difficulties in achieving satisfactory anesthesia, the procedure demands considerable technical expertise. The lack of available working space in infants also remains a major hurdle. We demonstrate an operative exercise of transperitoneal laparoscopic dismembered pyeloplasty in a 3-month-old girl and discuss the points of technique. Methods: All patients are evaluated in detail. Imaging included ultrasonography (USG), magnetic resonance urogram (MRU), and diuretic renogram (DR). Patients with gross pelvicaliceal dilatation with compromised renal function were planned for definitive repair. All patients were planned for dismembered pyeloplasty through transperitoneal access. Pneumoperitoneum was maintained at 10 mm of mercury. Usage of thermal energy was restricted during ureteric and pelvic mobilization. After delineation of the pathological segment, dismemberment and exclusion of the pathological segment was undertaken. The ureter was spatulated posterolaterally. Pelvic spatulation was conducted till the most dependent part. Redundant pelvis was excised. Pelviuretric anastomosis was conducted using interrupted sutures of 4-0 polyglactin. Additional pelvic closure was performed in a continuous fashion. A Double-J stent was inserted antegrade after completion of posterior layer of anastomosis. Postprocedure patients were allowed orally once comfortable and discharged after removal of drain and perurethral catheter. Ureteral stents were removed at 6 weeks postprocedure. Patients were followed 3 monthly postprocedure. At 1 year postprocedure, USG, MRU, and DR were evaluated. No intervention during intervening period (ureteral stent, nephrostomy, or redo procedure) and improvement in imaging parameters were considered a successful outcome. Results and Discussion: Twenty-two laparoscopic pyeloplasties were performed in infants between January 2004 and December 2011. Mean age was 6.4 months (range: 3 months to 1 year). Thirteen were males and nine females. Seven patients underwent temporary diversion (percutaneous nephrostomy) before laparoscopic pyeloplasty that was removed at the time of surgery. All procedures were completed by laparoscopy. Mean operation duration was 140.5 minutes. In three patients, antegrade insertion of ureteral stent was not possible. All patients tolerated orals within 12 hours postprocedure. Mean hospital stay was 4.5 days (range: 3–5 days). Nineteen patients (86.36%) completed 1-year follow-up. No patients required any additional intervention in the intervening period. All patients demonstrated improvement in renogram parameters. Among the available options for management of pelviureteric obstruction, a dismembered pyeloplasty has been reported with superior results.1 Although technically demanding, laparoscopic approach can be undertaken in infants. The morbidity profile and appreciable outcome were chief attributes of this approach. The operator should be sufficiently versed with laparoscopic anatomy and intracorporeal suturing exercises. No competing financial interests exist. Runtime of video: 6 mins 13 secs

Laparoscopic Reconstructive Procedures in Duplex Moieties: Points of Technique and Outcome

Abstract Introduction: Duplex moieties may present with a wide range of pathologies, obstruction and reflux being the most common.1 Reconstruction in duplex moieties is challenging, as integrity of both moieties needs to be meticulously preserved. Although the laparoscopic approach has been increasingly employed for different urological reconstructions, the laparoscopic approach for restoration of different pathologies in duplex moieties has been reported sparingly.2,3 We demonstrate operative exercises of laparoscopic reconstructions of various pathologies in duplex moieties. Methods: All patients were evaluated in detail, including clinical and biochemical profiles. Imaging included ultrasound, computed tomography or magnetic resonance urogram, voiding cystourethrogram, and retrograde pyelogram. Cystoscopy was performed to rule out concomitant bladder pathologies. Diuretic renogram was ordered to ensure salvagability of the pathological moiety. All procedures were performed through the laparoscopic appr...

A Novel Method of Evaluating Ureteropelvic Junction Obstruction: Dynamic Near Infrared Fluorescence Imaging Compared to Standard Modalities to Assess Urinary Obstruction in a Swine Model

Dynamic near infrared fluorescence imaging of the urinary tract provides a promising way to diagnose ureteropelvic junction obstruction. Initial studies demonstrated the ability to visualize urine flow and peristalsis in great detail. We analyzed the efficacy of near infrared imaging in evaluating ureteropelvic junction obstruction, renal involvement and the anatomical detail provided compared to conventional imaging modalities. Ten swine underwent partial or complete unilateral ureteral obstruction. Groups were survived for the short or the long term. Imaging was performed with mercaptoacetyltriglycine diuretic renogram, magnetic resonance urogram, excretory urogram, ultrasound and near infrared imaging. Scoring systems for ureteropelvic junction obstruction were developed for magnetic resonance urogram and near infrared imaging. Physicians and medical students graded ureteropelvic junction obstruction based on magnetic resonance urogram and near infrared imaging results. Markers of vascular and urinary dynamics were quantitatively consistent among control renal units. The same markers were abnormal in obstructed renal units with significantly different times of renal phase peak, start of pelvic phase and start of renal uptake. Such parameters were consistent with those obtained with mercaptoacetyltriglycine diuretic renography. Near infrared imaging provided live imaging of urinary flow, which was helpful in identifying the area of obstruction for surgical planning. Physicians and medical students categorized the degree of obstruction appropriately for fluorescence imaging and magnetic resonance urogram. Near infrared imaging offers a feasible way to obtain live, dynamic images of urine flow and ureteral peristalsis. Qualitative and quantitative parameters were comparable to those of conventional imaging. Findings support fluorescence imaging as an accurate, easy to use method of diagnosing ureteropelvic junction obstruction.