Management Of Pelvi-ureteric Junction Obstruction Research Articles

Robotic pyeloplasty: technological global panacea or geo-surgical nightmare?

To the Editor, Pelvi-ureteric junction obstruction (PUJO) is a well-recognised clinical entity characterised by functionally significant impairment of drainage of urine at the level of the pelvi-ureteric junction due to extrinsic or intrinsic obstruction and is encountered both by adult and paediatric urologists alike. Management of PUJO has been surgical historically, and the gold standard has been an open Anderson-Hynes dismembered pyeloplasty. [...].

Outcome of Dismembered Pyeloplasty in Children with Unilateral Pelviureteric Junction Obstruction: A Retrospective Observational Study

Introduction: Anderson-Hynes (AH) dismembered pyeloplasty is the standard procedure performed for the management of Pelviureteric Junction Obstruction (PUJO). Ultrasonography (USG) and diuretic renography are of great importance for the diagnosis and follow-up of PUJO. Aim: To evaluate the morphological and functional outcomes of open dismembered pyeloplasty in children with unilateral PUJO and to find the correlation between functional and morphological outcomes. Materials and Methods: A retrospective observational study was conducted, assessing the clinical charts of 200 children under 10 years of age with congenital PUJO who underwent open AH dismembered pyeloplasty in the Department of Paediatric Surgery at a teritary teaching Institute, Government medical college, Thiruvananthapuram, Kerala, India from from June 2015 to June 2020. The preoperative radiological assessment included renal USG and diuretic renography for all patients. Morphological and functional surgical outcomes were measured one year after surgery. The morphologic parameters analysed were the Anteroposterior Diameter (APD) of the pelvis and Parenchymal Thickness (PT). The functional outcome was assessed by improvements in Glomerular Filtration Rate (GFR), Split Renal Function (SRF), and drainage curve. Success was defined as improvement in function and morphology in followup USG and renogram after one year of surgery. Paired t-test was applied for statistical analysis using Statistical Package for the Social Sciences (SPSS) software version 23.0. Results: Among the total 200 patients,180 (90%) cases demonstrated improved renal function after pyeloplasty. Among the total 200 cases, males were 120 (60%) and females were 80 (40%). Morphologic outcome improved in 188 out of 200 (94%) cases. The overall outcome was good in 168 out of 200 (84%) patients. The results showed a moderate negative correlation for APD with respect to SRF (r=-0.677, p-value=0.01) and GFR (r=- 0.430, p-value=0.01), whereas a moderate positive correlation was observed between SRF and GFR (r=0.423, p-value=0.01). Conclusion: AH dismembered pyeloplasty is an effective treatment for PUJO in children, not only relieving obstruction but also improving renal function. The present study recommends considering both morphologic and functional parameters to assess the success of the surgery.

Laparoscopic management of pelvi-ureteric junction obstruction caused by aberrant renal vessels in an adult

Pelvi-ureteric junction obstruction is not a rare clinical entity. It is indeed one of the common urological conditions presenting most commonly as hydronephrosis and pain. The most common etiology for patients suffering from acquired pelvi-ureteric junction obstruction is the presence of calculus/calculi. An aberrant renal vessel (now termed as Vascular bar) is one of the causes in adults which is often missed on pre-operative investigations and is detected intra-operatively. We present herein, a case report of a 28 years old female who came with complaints of loin pain since 2 to 3 months. The workup investigations revealed only hydronephrosis without any calculi. Thus a diagnosis of primary pelvi-ureteric junction obstruction was made. The patient was successfully managed by a laparoscopic pyeloplasty.
 Keywords : PUJ obstruction, Vascular bar, aberrant renal vessel, laparoscopic pyeloplasty

Contemporary diagnosis and management of pelvi-ureteric junction obstruction.

Pelvi-ureteric junction obstruction (PUJO) is defined as a functionally significant impairment of the flow of urine from the kidney's renal pelvis into the proximal ureter. Symptomatically, the patient may experience flank pain, recurrent infections, stone formation, and impairment of renal function. Although many cases of intrinsic PUJO are diagnosed at birth, a minority of patients may present in adulthood with previously silent disease or develop secondary PUJO to other causes. PUJO is therefore broadly categorised into both primary and secondary PUJO. A wide array of diagnostic scans and tests are available to aid in diagnosing and monitoring patients with PUJO. In patients with compromised renal function or symptomatic PUJO that require intervention, minimally invasive techniques are the 'gold standard' for surgical intervention. This review will detail the endoscopic, laparoscopic, and robotic options available to the urologist practicing in 2021, including the use of autografts and other emerging technologies.

A comparative study between continuous and interrupted sutures in open pyeloplasty.

Pelvi-ureteric junction obstruction (PUJO) is one of the common causes of obstructive uropathy dealt by urologists around the globe. The management of PUJO requires surgical intervention and pelvi-ureteral anastomosis is most time-consuming step in surgery and suturing plays a critical role for the good outcome of the surgery. To assess the outcomes of continuous or interrupted suturing in open pyeloplasties done for PUJ obstruction. This comparative study was conducted in the department of Urology in a tertiary care hospital of eastern India. A total of 60 patients with pelviureteric junction obstruction were included as per inclusion and exclusion criteria and divided into two groups depending upon whether continuous (Group A) or interrupted (Group B) suturing was done. Both groups were compared for mean operative time, mean suturing time, duration of post-operative drainage, mean drain output, post-operative hospital stay, postoperative GFR and improvement in GFR. Out of 60 patients continuous and interrupted suturing was done in 30 patients in both arms. Out of 60 cases there were 46 (76.66%) males and 14 (23.33%) females with a M:F ratio of 1:0.30. The mean age in group A and group B was found to be 30.06 ± 8.28 and 27.63 ± 6.07, respectively. Mean operative time, mean suturing time, duration of post-operative drainage, mean drain output and postoperative hospital stay were found to be higher in interrupted suture group and the difference was found to be statistically highly significant (p < 0.0001). The complication rates and recurrence rates were found comparable in both the cases with no statistically significant difference (p > 0.05). Continuous suturing technique for pyeloplasty is preferable as it is found to have a lower mean operative time, mean suturing time, duration of post-operative drainage, mean drain output and postoperative hospital stay.

Outcome of Laparoscopic Versus Open Pyeloplasty in the Treatment of Pelviureteric Junction Obstruction: A Comparative Study

Background: Ureteropelvic junction obstruction leads to progressive dilatation of the renal collecting system, and can result in pain and progressive deterioration of renal function but may be asymptomatic and result in complication such as pyelonephritis,calculus formation and deterioration of renal function may ensue if left untreated.Open pyeloplasty remains the gold standard against which new technique must be compared.we compared laparoscopic and open pyeloplasty in the treatment of pelviureteric junction obstruction. To see the outcome of laparoscopic pyeloplasty versus open A-H pyeloplasty in the management of pelviureteric junction obstruction.&#x0D; Methods and materials: A prospective quasi experimental study was done from july 2012 to December 2013 in which a total of 30 laparoscopic and 30 open pyeloplasty were done. All laparoscopic pyeloplasties were performed transperitoneally.Standard open A H pyeloplasty,spiral flap or VY plasty was done depending on anatomical consideration. Patients were followed with USG and IVU at three and six months interval.Perioperative parameters including operative time,analgesic use,hospital stay,and complication and success rates were compared.&#x0D; Results: Mean total operative time in LP group was 115±15 min compared to 75 ±15 in OP group, the postoperative analgesic requirement was sighnificantly less in LP group(mean 84.73±11mg) and OP group required mean of( 274.33±39.42mg).The mean blood loss in LP group was 118.26±110.74ml compared to open group 274.82±118.97ml.The postoperative hospital stay in LP was mean 4 days(2-7days) sighnificantly less than the open group mean of 8 days(7-9days).&#x0D; Conclusion: Lp has a minimal level of morbidity and short hospital stay compered to open approach.Although laparoscopic pyeloplasty has the disadvantages of longer operetive time and requires sighnificant skill of intracorporal knotting but it is here to stay and represents an emerging standard of care.&#x0D; Bangladesh Journal of Urology, Vol. 22, No. 2, July 2019 p.182-187

Laparoscopic Treatment for Secondary Ureteropelvic Junction Obstruction

Background: Pelviureteric junction obstruction (PUJO) is one of the most frequent congenital anomalies of the urinary tract system. It is associated with pain, hydronephrosis, urinary tract infections, and eventually loss of renal function. Objective: To evaluate our institution in laparoscopic management of pelviureteric junction obstruction after failed open or laparoscopic surgery for pyeloplasty. Patients and methods: This study was conducted on 45 patients in two centers, Aswan Urology Department, and Sohage Urology Department. All of them have secondary pelviureteric junction obstruction. Results: This study included 24 females and 21 males, with the mean age of 30.2 ± 7.5 years (range 21 to 45 years), failed previous repair on the left side was in 29 cases while it was in 16 cases on the right side. Regarding BMI, it ranged from 21 to 30 with mean of 24.9 ± 3.1 kg/m2. The mean time after failure of primary pyeloplasty in both genders was 21.3 ± 8.2 months with a range of 10-38 months. The preoperative total renal function by DTPA was 80.7 ± 26.5. All cases were done laparoscopically without conversion to open surgery with a mean operative time of 154.9 ± 25.4 minutes (range from 80 to 185 minutes). The intra operative etiological finding of previous failure were peripelvic fibrosis and scarring in 34 cases, proximal ureteric stricture in 4, missed lower pole crossing vessels at initial surgery in 5 and a kink at the PUJ associated with redundant pelvis in two patients. Conclusion: Laparoscopic pyeloplasty is an effective minimal invasive alternative to open surgery in treatment of secondary pelviureteric junction obstruction.

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.

English

English

Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes.

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances.Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures.Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame.Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

Management of pelviureteric junction obstruction at a tertiary teaching hospital in southwestern Nigeria: A retrospective analysis of case records

Background: Pelviureteric junction obstruction (PUJO) is an important cause of upper urinary tract obstruction. It can cause marked impairment of renal function, especially in bilateral cases, if not diagnosed and treated promptly. Surgical intervention is currently the mainstay of treatment. We aimed to review the pattern of presentation and management outcomes of patients diagnosed with PUJO. Methods: We conducted a retrospective study of patients aged 2–60 years who presented with PUJO between January 2005 and December 2014. Demographic characteristics, clinical presentation, investigations, and treatment modalities were extracted from case notes. Data were analysed using SPSS version 20. Results: The age range of the 32 included PUJO patients was 2–60 years, with a median age of 30 years. Children constituted 31% of patients. There were 15 males and a male-to-female ratio of 0.88:1. Most PUJO was unilateral and left-sided (n = 19; 59%). Loin pain was the commonest symptom (n = 26; 81%), while 25% of patients had a urinary tract infection at presentation. All patients had normal renal function at the time of surgery, and Anderson–Hynes pyeloplasty was the most common technique employed (72% of cases). Postoperatively, the majority of patients (n = 31; 97%) had complete symptom resolution. Surgical site infection (n = 3; 9%) was the commonest postoperative complication, and the median hospital stay was 11 days. There was no mortality. Conclusions: Most patients with PUJO presented late. Most of our patients underwent Anderson–Hynes pyeloplasty with satisfactory outcomes. https://dx.doi.org/10.4314/ecajs.v23i1.6 This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source (including a link to the formal publication), provide a link to the Creative Commons license, and indicate if changes were made.

Laparoscopic management of pelvi-ureteric junction obstruction after failed open surgery or Laparoscopic pyeloplasty in adults

Objectives: a prospective study of our experience and midterm results of laparoscopic pyeloplasty (LP) for patients who have failed open or Laparoscopic pyeloplasty in adults. Patients and methods: Thirty two patients with failed open pyeloplasty were reviewed; all of them had transperitoneal dismembered LP. All procedures were performed by experienced laparoscopist during a period of two years. Results: The study group consisted of 14 men and 18 women with the mean age of 29± 6 years. Mean operative time was 123± 22 minutes. Mean hospital stay was 4.7 ± 2.3 days. Mean follow-up was 5.6 ± 2.15 months (range 3-9 months). The overall success rate for secondary LP was 90.6%. There was no conversion to open surgery. Intraoperative and postoperative complications were 9.4 and 12.5% respectively. Conclusions:LP is a safe and viable treatment option for secondary pelviureteric junction obstruction with high success rate but with long operative time. A good experience in laparoscopic reconstructive procedures is a prerequisite for optimal results.

Anderson-Hynes pyeloplasty: are we all really on the same page?

The Anderson-Hynes pyeloplasty (AHP) is a surgical technique used in the management of pelvi-ureteric junction obstruction. This operation has been performed for over six decades and has etched its name in the annals of urology. But are we all really referring to the same procedure? A systematic review of the Ovid MEDLINE(R) and Ovid OLDMEDLINE(R) database from 1946 to 20 June 2014 was performed for the terms 'Anderson and Hynes' and 'Anderson-Hynes', with later restriction to the title of journal article. Each respective author's descriptive images (figures/photographic) of technique performed was compared with the original procedure. Non-English figure legends were translated using online translational tools. In total, 242 articles were retrieved. Streamlining this search to articles with the above search terms restricted to article title revealed 58 (34 English/24 non-English) articles. Only 29/58 papers had referenced the original procedure. Operative images were present in 17/58 of the articles claiming to have performed the AHP. Within these papers, only 7/17 articles depicted both the L-shaped cut and pelvic flap. Diverse variations were observed in the remainder 10/17 articles. This was a worldwide phenomenon, observed more commonly in recent decades and when minimally invasive techniques were used. The AHP is often not performed as was originally described. Over the decades, surgeons have unknowingly attributed variations to this procedure. Based on this review, a novel 'geometric classification' system has been proposed to better define the dismembered pyeloplasty.

Pelvi-ureteric junction obstruction in adults in a resource limited environment: Causes, features and outcome of treatment

Objective: To report our experience with the management and outcome of treatment of adults with pelvi-ureteric junction(PUJ) obstruction Subjects and Methods: This was a retrospective study of adults with PUJ obstruction from January 2009 to December 2013. The study was conducted at a Tertiary Teaching Hospital in Ibadan in Nigeria. All adults with clinical features and radiological evidence of PUJ obstruction were included. Some patients had non operative treatment while others had open surgical treatment. The main outcome of treatment was measured by the relief of symptoms. We are not aware of previous report of the management of PUJ obstruction in adults in Nigeria. Results: Eighteen adult patients were treated. The mean age was 39 ± 11.2 standard deviation years (range 20-65 years). Seventy-two percent presented with loin pain. Thirteen of these patients were treated surgically, and 5 were treated nonoperatively. The operation findings were narrow but patent PUJ that barely admit a probe due to intrinsic muscle fibrosis in six patients, aberrant crossing vessels in 3, severely hydronephrotic kidneys in 3 and one impacted PUJ calculus. Fifty percent of patients had open dismembered pyeloplasty, simple nephrectomy (16.7%) while combined pyelolithotomy and Foley Y-V plasty (5%). All surgically treated patients were pain-free as at last time of review. Conclusion: Intrinsic muscle fibrosis and aberrant crossing vessels are the most common causes of PUJ obstruction in adults. Open pyeloplasty is still the main stay of treatment in our environment with satisfactory symptomatic relief.

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

Laparoscopic Dismembered Pyeloplasty Through Transmesocolic Approach: Point of Technique and Our Experience

Inroduction: Laparoscopic dismembered pyeloplasty is considered as the gold standard for the management of pelviureteric junction obstruction. Conventional laparoscopic pyeloplasty through a transperitoneal approach mandates colonic mobilization for access to the pathological segment. In selected individuals (with minimal mesenteric fat), a transmesocolic approach may be attempted and colonic handling can be avoided. The transmesocolic approach offers several advantages. Colonic mobilization may be attended with a prolonged procedural duration, increased blood loss, possibility of iatrogenic insults, and delayed recovery.1,2 With the transmesocolic approach, these problems can be reduced. We present a video demonstration of laparoscopic transmesocolic pyeloplasty. Port positions are depicted in the illustration. After achieving the pneumoperitoneum, the left renal pelvis and upper ureter were clearly visible through the mesocolon in this patient. This motivated us to embark on the transmesocolic approach. A transmesocolic window was created with selective generation of electrocautery. The ureter was dissected and traced upto the pelviureteric confluence. Periureteric and peripelvic adhesiolysis was performed using cold scissors, refraining from overvigorus usage of electrocautery. After delineation of the pathological segment, dismemberment was undertaken and pyelotomy was conducted. Ureter was adequately spatulated posterolaterally to ensure a wide anastomosis. Tension-free pelviureteric approxamibility was ascertained. Pelviuretreic approximation was undertaken using 4-0 polyglactin. The corner stitch was taken incorporating the apex of the spatulated ureter and the most dependent part of the pelvis. The opposite corner was approximated next followed by completion of the anterior layer of closure. The suture line was then upturned and attention directed to the posterior layer of pelviureteric approximation. A stent was inserted in an antegrade fashion. The redundant pelvis was excised and the posterior layer closure was completed by approximating the edges of the remaining pelvis. Hemostasis was achieved and a drain was inserted. The mesocolic window was closed. Materials and Methods: A 3-year-old male child was diagnosed with left pelviureteric junction obstruction after detailed evaluation. Retrograde dye delineation confirmed short segment left pelviureteric narrowing. Laparoscopic dismembered pyeloplasty through the transperitoneal route was contemplated. Operative and postoperative details were recorded. Patient was followed up at regular intervals. We analyzed the perioperative and long-term functional outcome of all patients who underwent transmesocolic pyeloplasty at our center. Results and Conclusion: Totally 41 patients underwent transmesocolic dismembered pyeloplasty at our institution. Thirty patients were of the pediatric age group and remaining were adults. The mean stricture length was 1.2 cm and a crossing vessel was present in seven patients. The mean duration of surgery was 70 minutes, mean blood loss was 100 mL. The mean time to start orals was 12 hours, mean duration of hospital stay was 36 hours, mean duration of follow up was 45 months. The success rate was 97.5%. Transmesocolic dismembered pyeloplasty is a safe and feasible procedure with less morbidity and satisfactory functional outcome. However, the transmesocolic approach may be practiced in individuals with short segment pelviureteric narrowing as the mesocolic window does not allow wide mobilization of the pelvis and upper ureter. Additionally, this approach is applicable in individuals with minimal mesocolic fat, which is typically encountered in children or thin individuals. No competing financial interests exist. Runtime of video: 4 mins 55 secs

Pyeloplasty for Pelvi-Ureteric Junction Obstruction in Malrotated Kidneys in Children

Pelvi-ureteric junction (PUJ) obstruction associated with malrotated kidney is very rare. In such cases, dismembered pyeloplasty poses technical difficulties. We present our experience with management of PUJ obstruction in malrotated kidneys in children and their outcomes. Retrospective review of case notes of all children who had pyeloplasty for PUJ obstruction associated with malrotated kidneys, over a period of 7 years between January 2003 and December 2009 at our institution. We identified four patients, and all four patients had malrotated kidneys with a lateral and slightly inferior facing renal pelvis. Anderson and Hynes dismembered pyeloplasty with inferior pelvi-ureteric anastamosis was performed in two patients (one patient with nephropexy and one patient without nephropexy), but failed to improve the drainage across the PUJ in both the patients. The remaining two patients underwent a dismembered pyeloplasty with anterior pelvi-ureteric anastamosis that resulted in a good drainage. One of the patients who had pyeloplasty with inferior pelvi-ureteric anastamosis had a redo pyeloplasty with anterior pelvi-ureteric anastamosis that restored the drainage adequately. In our experience dismembered pyeloplasty with inferior pelvi-ureteric anastamosis along with or without nephropexy has not been successful in cases of PUJ obstruction in laterally malrotated kidneys. Although the number of cases in our study is small, we have had a 100% success with dismembered pyeloplasty with anterior pelvi-ureteric anastamosis. The authors are of the opinion that this modified approach is recommended as a viable option both as a primary and salvage procedure for PUJ obstruction in laterally malrotated kidneys.

Laparoscopic vs Open Pyeloplasty

This review article compares open versus laparoscopic management of pelviureteric junction obstruction (PUJO). Untreated PUJO willcause hydronephrosis and gradual renal impairment. Using PubMed, Google, Journal of Minimal Access Surgery (JMAS), Medscape,European Urology Journal and SpringerLink internet search engines, I reviewed several articles that have tried to find out which way isbetter. Most of the articles I reviewed showed that laparoscopic pyeloplasty (LP) is as good as open pyeloplasty (OP) and has additionaladvantages. The parameters that were evaluated included operative time, the use of pain killers (analgesic), period of hospitalization andcomplications.Conclusion: Most of the studies agreed on that LP had less morbidity and less hospital stay than OP, but the main disadvantage was thelonger operative time.

Conservative Management of Pelvi-Ureteric Junction Obstruction (PUJO): Is it Appropriate and If So How Long is Follow-up Needed?

Conservative Management of Pelvi-Ureteric Junction Obstruction (PUJO): Is it Appropriate and If So How Long is Follow-up Needed?

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.