Obstructed Ureteropelvic Junction Research Articles

Simultaneous laparoscopic surgery for ureteropelvic junction obstruction and retrograde intrarenal surgery for nephrolithiasis

Objective: To determine the surgical possibilities of the one-stage laparoscopic repair in the obstructed ureteropelvic junction (UPJ) complicated with nephrolithiasis in combination with the retrograde intrarenal surgery.Case report: The patient A., a 36-year-old male complaining about dragging pains in the right lumbar region was admitted to Urology Unit No. 1 of Krasnodar Regional Clinical Hospital No. 2. The patient underwent ultrasound examination, CT, and dynamic renal scintigraphy. The findings were as follows: the enlargement of pelvicalyceal system in the right kidney (calyx up to 22 mm, pelvis up to 50 mm), 5 calyx concrements and 2 pelvic concrements 6 to 8 mm in size, obstruction at the level of the right UPJ up to 10 mm in length, III grade hydronephrosis on the right according to Lopatkin classification.Conclusions: The combination of laparoscopic surgery and retrograde intrarenal surgery with the flexible ureteroscope and holmium laser is an effective and safe method for the treatment of UPJ obstruction complicated with nephrolithiasis.

Robotic Urologic Surgery in the Infant: a Review.

The goal of this article is to review the current role of robotic urologic surgery in the infant population across a spectrum of diseases and procedures. Robotic urological surgery has been performed in the infant population across a variety of conditions including ureteropelvic junction obstruction, vesicoureteral reflux, and duplicated and nonfunctional renal moieties. However, most of the durable evidence showing safety and success remains in the repair of the obstructed ureteropelvic junction. Included in this review are also strategies to address the limitations imposed by the unique physiology and anatomy of the infant. Robotic urologic surgery remains an alternative to other surgical approaches in the properly selected infant in the hands of experienced surgeons. As additional larger studies are performed, the utility of the robotic platform in this population will be clearer.

Does the histopathologic pattern of the ureteropelvic junction affect the outcome of pyeloplasty.

To investigate the effects of the histopathologic pattern of obstructed ureteropelvic junction (UPJ) specimens, including collagen type 3, elastin, fibrosis and Cajal cells, on the outcome of pyeloplasty. Histopathological specimens obtained following Anderson-Hynes pyeloplasty from 52 patients with intrinsic ureteropelvic junction obstruction (UPJO) between January 2005 and January 2008 were evaluated histopathologically. Patients with extrinsic or secondary UPJO were excluded. Preoperative and postoperative radiographic evaluations were performed either via diuretic renography or intravenous pyelography, or both. Six months post-surgery the patients were divided into 2 groups, as successful surgery (group 1) and unsuccessful surgery (group 2). Histopathological findings (collagen type 3, elastin, fibrosis and Cajal cells) in each group were statistically compared. The study included 52 patients (21 female and 31 male). Mean age of the entire study population was 39.42 ± 14.5 years, versus 39.63 ± 14.9 years in group 1 (n = 47) and 37.4 ± 10.0 years in group 2 (n = 5). Median follow-up was 18 months. There weren't any significant differences in collagen type 3, elastin, fibrosis, or Cajal cells between the 2 groups (P > .05). The histopathologic pattern of UPJ was not a factor associated with the success of pyeloplasty. Based on the present findings, we conclude that surgical technique is more important than the histopathologic pattern of UPJ for the successful treatment of UPJO.

Use of 3-Dimensional Printing Technology and Silicone Modeling in Surgical Simulation: Development and Face Validation in Pediatric Laparoscopic Pyeloplasty

Pediatric laparoscopy poses unique training challenges owing to smaller workspaces, finer sutures used, and potentially more delicate tissues that require increased surgical dexterity when compared with adult analogs. We describe the development and face validation of a pediatric pyeloplasty simulator using a low-cost laparoscopic dry-laboratory model developed with 3-dimensional (3D) printing and silicone modeling. The organs (the kidney, renal pelvis, and ureter) were created in a 3-step process where molds were created with 3D modeling software, printed with a Spectrum Z510 3D printer, and cast with Dragon Skin 30 silicone rubber. The model was secured in a laparoscopy box trainer. A pilot study was conducted at a Canadian Urological Association meeting. A total of 24 pediatric urology fellows and 3 experienced faculty members then assessed our skills module during a minimally invasive surgery training course. Participants had 60 minutes to perform a right-side pyeloplasty using laparoscopic tools and 5-0 VICRYL suture. Face validity was demonstrated on a 5-point Likert scale. The dry-laboratory model consists of a kidney, a replaceable dilated renal pelvis and ureter with an obstructed ureteropelvic junction, and an overlying peritoneum with an inscribed fundamentals of laparoscopic surgery pattern-cutting exercise. During initial validation at the Canadian Urological Association, participants rated (out of 5) 4.75 ± 0.29 for overall impression, 4.50 ± 0.41 for realism, and 4.38 ± 0.48 for handling. During the minimally invasive surgery course, 22 of 24 fellows and all the faculty members completed the scoring. Usability was rated 4 or 5 by 14 participants (overall, 3.6 ± 1.22 by novices and 3.7 ± 0.58 by experts), indicating that they would use the model in their own training and teaching. Esthetically, the model was rated 3.5 ± 0.74 (novices) and 3.3 ± 0.58 (experts). We developed a pediatric pyeloplasty simulator by applying a low-cost reusable model for laparoscopic training and skills acquisition. The model's usability, realism, and feel are good, it can be imaged under common modalities, and it shows promise as an educational tool.

The distribution of interstitial cells of Cajal in congenital ureteropelvic junction obstruction

PurposeThe authors analysed the distribution of c-kit-positive interstitial cells of Cajal (ICCs) in obstructed ureteropelvic junction (UPJ) and its age-related changes.MethodsTwenty specimens were obtained from children with intrinsic ureteropelvic junction obstruction (UPJO), at the average age of 8.1 years (8 months–16.8 years), fixed in formalin and embedded in paraffin. Five control samples were taken from children at the average age of 2.3 years (2.4 months–7.4 years). All specimens were analysed by the immunohistochemistry test with light microscopy with respect to c-kit expression. The distribution of c-kit-positive ICCs in the two groups was compared and the correlation between the distribution of c-kit-positive ICCs and the patients’ age in UPJO cases was analysed. The results were examined by Yates’ χ2 test, Mann–Whitney U test, and t test for Pearson’s correlation coefficient. A P value < 0.05 was considered as statistically significant.ResultsNo statistically significant differences were found in the distribution of c-kit-positive ICCs between UPJO and the control group. No correlation was established between the age of patients with UPJO and the distribution of c-kit-positive ICCs.ConclusionNo distributional difference found in obstructed and unobstructed UPJ seems to indicate that UPJO is not associated with anomalous distribution of c-kit-positive ICCs. Age-related changes in the expression of c-kit-positive ICCs are equally distributed in obstructed UPJ.

National Trends and Disparities in the Use of Minimally Invasive Adult Pyeloplasty

Minimally invasive pyeloplasty might have several advantages compared to open pyeloplasty in the management of ureteropelvic junction obstruction. Nonetheless, minimally invasive pyeloplasty appears to be underused in North America. We examined specific patient and hospital characteristics that may be associated with these disparities. The Nationwide Inpatient Sample was used to identify a national estimate of 29,456 patients with ureteropelvic junction obstruction treated with minimally invasive pyeloplasty (laparoscopic or robotic) and open pyeloplasty between 1998 and 2009. The rates of use of minimally invasive and open pyeloplasty were assessed according to year of surgery, and patient and hospital characteristics. The determinants of minimally invasive pyeloplasty were evaluated using logistic regression models adjusted for clustering. Overall 15.3% of patients underwent minimally invasive pyeloplasty between 1998 and 2009. The use of minimally invasive pyeloplasty increased remarkably during the study period from 2.4% to 55.3%, a 23-fold increase. On multivariable logistic regression analysis African-American race (OR 0.584, p = 0.015) and other insurance status (including uninsured patients, OR 0.613, p = 0.013) were associated with a lower rate of minimally invasive pyeloplasty. Patients treated at teaching (OR 1.788, p = 0.003) and/or urban (OR 4.819, p <0.001) institutions were significantly more likely to undergo minimally invasive pyeloplasty. In the last decade there has been a dramatic increase in the use of minimally invasive pyeloplasty in the United States and in 2009 a slight majority underwent minimally invasive pyeloplasty. Nonetheless, treatment disparities exist. African-American patients with other insurance status (including those uninsured) treated at nonteaching, rural hospitals were less likely to undergo minimally invasive pyeloplasty. Efforts should be made to understand these treatment disparities and broaden the availability of minimally invasive pyeloplasty.

Coagulum Pyelolithotomy “Revisited” by Laparoscopy: Technique Modification

Laparoscopic ureteropyeloplasty is a widely accepted treatment option for the obstructed ureteropelvic junction (UPJ). Although it is often a straightforward surgical procedure, there may be technical difficulties in the case of concomitant stone burden, with multiple calicial, small, mobile stones. The authors describe a modification to the classic coagulum pyelolitothomy, using a mixture based on commercially available fibrin sealant, first used in the laparoscopic era. During a laparoscopic transperitoneal dismembered ureteropyeloplasty complemented with coagulum pyelolithotomy, the following steps are suggested: (1) Exposure of the UPJ; (2) ureter clamping with a vessel loop 2 cm distal to the UPJ (to allow pelvis filling); (3) transabdominal puncture of the pelvis with an 18-G, 20-cm needle (under laparoscopic vision) and urine aspiration; (4) recording the volume of urine aspirated; (5) preparing an equal volume of fibrin sealant (to avoid overdistention of the pelvis); (6) injecting the sealer protein solution through that needle + 1 mL of methylene blue (color the coagulum and facilitate its identification in the removal procedure); (7) insertion of another needle to inject the thrombin solution; (8) wait 5 minutes to allow coagulum cast formation; (9) circumferential excision of the UPJ; (10) coagulum removal; (11) pelvis plastic reduction (if needed) and ureter spatulation; (12) double-J stent placement; and (13) tension-free anastomosis completion. The procedure results in the extraction of a tenacious coagulum containing more stones than normally anticipated from the x-ray studies. This technique modification reduces the incidence of incomplete stone removal, when there are small, free stones lying in a large renal pelvis.

Changes in interstitial cell of Cajal-like cells density in congenital ureteropelvic junction obstruction

PurposeThe authors examined the number of interstitial cells of Cajal-like cells (ICC-LCs) in obstructed ureteropelvic junction (UPJ) in comparison with normal UPJ specimens and age-related changes.Materials and methodsA total of 20 human formalin fixed, paraffin-embedded specimens of intrinsic UPJO from children at the mean age of 8.1 years (age range: 8 months–16.8 years) and 5 control samples from children at the mean age of 2.3 years (range 2.4 months–7.4 years) were investigated immunohistochemically for the expression of c-kit proto-oncogene by light microscopy with computerized image analysis. The results were examined by Fisher’s exact test, Yates’ chi-square test, and t test for Pearson’s correlation coefficient. A P value less than 0.05 was considered statistically significant.ResultsThe number of ICC-LCs-dense fields was significantly higher in UPJO specimens in comparison with the normal group (P = 0.0004). The number of ICC-LCs-sparse fields was significantly lowered in UPJO specimens in comparison with the normal group (P = 0.0122). There was no significant difference in the number of ICC-LCs-medium fields in obstructed and normal UPJ specimens. The number of ICC-LCs was decreasing significantly with increasing age of the patients with UPJO (P = 0.0038).ConclusionsThe higher density of c-kit-positive ICC-LCs in UPJ may manifest the compensation of altered peristalsis in UPJO. The number of ICC-LCs-dense fields decreasing with age may show the failure of compensation and regression of the compensatory changes.

Role of Endoluminal Sonography in Evaluation of Obstruction of the Ureteropelvic Junction

The objective of this study was to evaluate the clinical feasibility of the use of 2D and 3D endoluminal sonography during endourologic procedures on patients with an obstructed ureteropelvic junction (UPJ). In 45 patients with an obstructed UPJ undergoing endoscopic procedures, a 6.2-French catheter-based ultrasound probe (12.5 or 20 MHz) was inserted under endoscopic guidance into the upper urinary tract for acquisition of 2D images for evaluation of UPJ structures and construction of 3D volume images with a computer workstation. The role of 3D in addition to 2D imaging for identification of abnormalities at the UPJ was evaluated. Both 2D and 3D images depicted crossing vessels at the UPJ in 24 of 43 patients (55.8%) and a ureteral septum in 14 of 43 patients (32.6%), and endoscopic incisions were successfully made with sonographic guidance. The anatomic structures of the UPJ associated with abnormalities (e.g., crossing vessels, septum, calculi, tumors, and strictures) were appreciated and evaluated more fully on 3D than on 2D images. The endoluminal sonographic findings helped rule out or modify the interventional procedure (endopyelotomy or balloon ureteroplasty) in the cases of eight of 43 patients (18.6%). Three-dimensional endoluminal sonography clearly displays diagnostic information that complements 2D imaging findings and enhances the assessment of normal and abnormal structures at the UPJ for endourologic surgery.

Pyéloplastie laparoscopique

Ureteropelvic junction (UPJ) obstruction in adults is usually symptomatic, secondary, and it tends to progress. Surgical correction of obstructed UPJ is necessary to preserve the renal function of the affected kidney. Pyeloplasty as a surgical management for UPJ obstruction in adults has proven its efficacy with high success rates on long-term results. Laparoscopic pyeloplasty in the management of primary or secondary UPJ obstruction in adults technically duplicate the open surgical technique. Laparoscopic pyeloplasty has developed to match success, morbidity and complication rates of open surgical pyeloplasty. However it was shown that laparoscopy had consistently a shorter convalescence than open surgery. Endopyelotomy is utilized to manage UPJ obstruction. Early results for endopyelotomy were promising but long-term results were not encouraging. In the management of UPJ obstruction in adults, long-term success rates for laparoscopic pyeloplasty were found to be superior to those of endopyelotomy. Therefore we believe that laparoscopic pyeloplasty will become as a standard management for UPJ obstruction in adults.

Laparoscopy Versus Dorsal Lumbotomy for Ureteropelvic Junction Obstruction Repair

Laparoscopic pyeloplasty offers similar success rates compared to open surgery. However, the advanced laparoscopic skills required may limit its widespread application. In select patients the dorsal lumbotomy approach can provide similar postoperative advantages to minimally invasive surgery. We analyze the perioperative management of laparoscopy vs dorsal lumbotomy for the repair of ureteropelvic junction obstruction. In a retrospective review 13 patients who underwent dorsal lumbotomy pyeloplasty were compared to 19 patients who underwent laparoscopic pyeloplasty between 1998 and 2003. Preoperative confirmation of obstruction was obtained through excretory urogram or renal Lasix scan. All 13 patients undergoing dorsal lumbotomy had a dismembered pyeloplasty. Of the 19 laparoscopic cases 16 had a dismembered pyeloplasty and 3 had a Fenger procedure. Average followup was 12 months for the open group and 13.3 months for the laparoscopic group. Postoperative results were evaluated with excretory urogram or renal Lasix scan as well as subjective outcomes by the patients. Operative time was slightly longer for the laparoscopy group at 231 minutes vs 200 minutes. Estimated blood loss and postoperative morphine requirements were also similar. Hospital stay was 3.3 days for the dorsal lumbotomy group compared to 2.4 for the laparoscopy group. The overall success rate for the laparoscopic group was 94.7% compared to 100% for the dorsal lumbotomy group. Each group had 1 complication, paresthesia of anterior/medial thigh that resolved by 6 months. Our preliminary results show that a dismembered dorsal lumbotomy pyeloplasty is comparable to laparoscopic dismembered pyeloplasty with regard to intraoperative and postoperative hospital course.

Smooth Muscle Cell Apoptosis and Defective Neural Development in Congenital Ureteropelvic Junction Obstruction

We assessed the smooth muscle cell apoptosis along with changes in cellular and extracellular components of the ureteropelvic junction in 23 patients with unilateral obstruction and compared them with 25 autopsies from ureteropelvic junction regions of age matched cadavers. Tissue specimens obtained from pyeloplasty were divided into 3 sections-renal pelvis above the obstruction, obstructed ureteropelvic junction and ureter below the obstructed region. For the control group the normal ureteropelvic junctions of age matched infants were autopsied. In paraffin embedded sections we determined myocyte apoptosis index (using TUNEL assay), and the amount of muscular components and nerve terminals (using image analysis techniques after immunohistochemical staining). The collagen and elastin fibers were specifically stained for evaluation of changes in extracellular matrix. Smooth muscle cell apoptosis index was significantly increased at the site of ureteropelvic junction obstruction (5.68 +/- 0.18) compared to normal autopsied ureteropelvic junctions (3.60 +/- 0.11) and 2 other sections of obstructed ureteropelvic junction complex (renal pelvis 4.73 +/- 0.16, and ureter 3.97 +/- 0.16). The number of nerve terminals and the percentage of muscular component were significantly lower at the obstructed segments of affected patients compared to normal ureteropelvic junctions. Meanwhile, collagen fibers formed a significantly higher proportion of ureteral wall at the site of obstruction. Interestingly, there was negative correlation between myocyte apoptosis indices and number of nerve endings as well as amount of muscular components at the site of ureteropelvic junction obstruction. However, positive correlations were found between smooth muscle cell apoptosis and the percentage of collagen and elastin fibers. Our findings suggest an important role for myocyte apoptosis and defective neural development in the pathogenesis of congenital ureteropelvic junction obstruction that could pave the road for the emergence of new therapeutic modalities.

Innervation of narrowed segment of upper ureter in children with ureteropelvic junction obstruction: Krakós M, Kobos J, Andrzejewska E. Urol Pol 2004(4);57:71-76

Obstruction of the ureteropelvic junction is a common cause of hydronephrosis in children and adolescents. The authors evaluated innervation of the obstructed ureteropelvic junction segment resected during reconstructive surgery in 50 children with hydronephrosis, aged 3 to 12 years. The nerve structures were identified (in number) immunohistochemically with the use of antibodies anti PGP 9.5 (protein gene product) and NGF-R (nerve growth factor receptor). The study revealed much worse innervation (P<0.001) of obstructed segments of ureters compared to normal ureters of children after nephrectomies from other causes (trauma, neoplasms). Significant differences in number and distribution of nerve structures in the muscular layer of the ureteral wall were observed within the obstructed segment group. Innervation of the ureteral wall was found to be less evident in older children (aged 8-12 yrs) compared to younger children (aged 3-7 yrs) (P<0.001). The results support the thesis that the autonomic nervous system controls ureteral peristalsis and urine transport from renal pelvis to bladder. However, it remains unresolved as to whether the observed changes represent the cause or are simply a consequence of obstruction.

Minimizing Minimally Invasive Surgery: The 5-mm Trocar Laparoscopic Pyeloplasty

Laparoscopic pyeloplasty has evolved into the procedure of choice when definitive repair of the obstructed ureteropelvic junction is contemplated. Its main advantage over the gold standard of open pyeloplasty is decreased morbidity. We have utilized only three 5-mm ports in our last 15 pyeloplasties in an effort to further reduce morbidity and improve acceptance by an often-younger patient population. Fifteen consecutive patients underwent laparoscopic transperitoneal pyeloplasty by the 5-mm port technique. Three trocars were utilized, two for the working instruments and one for a 5-mm telescope mounted on a voice-activated robotic arm (AESOP; Intuitive Surgical, Sunnyvale, CA). Three patients required an additional trocar for liver retraction. All patients underwent dismembered pyeloplasty and had indwelling double-pigtail stents placed for 4 to 6 weeks. The mean operative time was 195 minutes (range 120-240 minutes). The average blood loss was 30 mL. None of our patients required open conversion. With a median follow-up of 10 months (range 3-15 months), all 15 patients have shown both subjective (freedom from symptoms) and objective (renal scan) improvement. We believe our technique has further minimized the morbidity of laparoscopic pyeloplasty without compromising the outcome. The 5-mm trocars obviate fascial closure, decrease patient discomfort, and improve cosmesis. Furthermore, the use of the robotic arm eliminates the need for a surgical assistant and makes this an essentially "one-person" procedure.

ELASTIN CONTENT OF THE RENAL PELVIS AND URETER DETERMINES POST-PYELOPLASTY RECOVERY

We evaluated the collagen-to-smooth muscle tissue matrix ratio and percentage of elastin in the renal pelvis, ureteropelvic junction (UPJ) and ureter, and compared these findings with the degree of obstruction, patient age and post-pyeloplasty renal recovery. We analyzed histological sections from 75 patients with UPJ obstruction. Nine patients were excluded owing to bilateral UPJ obstruction and an improper specimen. We divided the specimen obtained from pyeloplasty into 3 parts, namely the renal pelvis above the obstruction, the obstructed UPJ portion and the ureter below the obstruction. To examine the collagen and smooth muscle, sections were stained using Masson's trichrome, and elastic van Giesson stain was used for elastin, smooth muscle and collagen. Collagen, smooth muscle and elastin populations were identified, and the tissue matrix ratio and percentage of elastin were calculated by color image analysis. In patients with lower ratios of collagen-to-smooth muscle in the UPJ proper hydronephrosis was more improved postoperatively (p = 0.049). In patients with a lower percentage of elastin in the renal pelvis, UPJ and ureter hydronephrosis was more improved postoperatively (p <0.0001). Because the UPJ portion was resected during pyeloplasty, the renal pelvis and the ureter remaining after pyeloplasty are likely to be related to improved hydronephrosis. A higher percentage of elastin in the renal pelvis and ureter contributes to inelasticity and low compliance, and results in a slower recovery from hydronephrosis after pyeloplasty.

Altered Expression of Interstitial Cells of Cajal in Congenital Ureteropelvic Junction Obstruction

Peristaltic contractions in the upper urinary tract serve to move urine from the kidney through the ureter to the bladder. Ureteropelvic junction (UPJ) obstruction is the most common cause of congenital hydronephrosis in children. To our knowledge the pathophysiology of UPJ obstruction is unknown. C-kit positive interstitial cells of Cajal (ICCs) are pacemaker cells that facilitate active propagation of electrical events and mediate neurotransmission. We investigated the expression of c-kit positive cells in the muscle layer of normal and obstructed UPJ specimens. A total of 19 human formalin fixed, paraffin embedded specimens of intrinsic UPJ obstruction from children with a mean age of 2.3 years (range 2 months to 12 years) and 7 control samples from children with a mean age of 4.5 years (range 11 months to 9 years) were investigated immunohistochemically for the expression of c-Kit oncoprotein and peripherin by light and laser scanning microscopy. Quantification of immunolabeled structures was quantified using computerized image analysis. Peripherin immunoreactivity was strong in the muscle layer of normal UPJ specimens, while in UPJ obstructed specimens there was a decrease in peripherin positive nerve fibers. In normal UPJ specimens there were many c-Kit positive ICCs between the muscle bundles. The density of ICCs was markedly decreased in the muscle layers of UPJ obstructed specimens. To our knowledge this study shows for the first time the immuno-expression of c-Kit positive ICCs in the proximal part of the normal human upper ureter. The altered density of c-Kit positive cells in UPJ obstruction may have a role in the failure of transmission of peristaltic waves across the UPJ.

Ureteropelvic junction anatomy

Currently the endoscopic treatment of ureteropelvic junction (UPJ) obstruction (endopyelotomy) is a common procedure, and it has replaced almost completely the standard open pyeloplasty in the treatment of primary and secondary UPJ obstruction [1]. Among the features proposed as causative of UPJ obstruction, the significance of crossing vessels still is controversial. When open or laparoscopic surgery is planned, this feature is rarely a problem because these vessels may be transposed with a dismembered pyeloplasty (whether necessary or not) [1]. Nevertheless, for endourologic procedures in the UPJ, these crossing vessels are important in regard to their functional and prognostic significance and as a potential source of bleeding during the procedure. A precise understanding of vascular anatomy is crucial when evaluating and managing the obstructed UPJ.

In vivo proteomic analysis of cytokine expression in laser capture-microdissected urothelial cells of obstructed ureteropelvic junction procured by laparoscopic dismembered pyeloplasty.

Ureteropelvic junction obstruction (UPJO) is defined as an impediment to urinary flow from the renal pelvis into the ureter. The exact cause remains an enigma despite investigations along embryologic, anatomic, and histologic lines. Our goal was to investigate in vivo the expression profile of cytokines in hyperplastic urothelial cells as a means of determining the source of UPJO. Cellular proteomes of matched normal and hyperplastic urothelial cells were analyzed by laser capture microdissection (LCM) and tissue microdissection and human cytokine proteomic chips. All specimens (N = 9) were surgically obtained from patients undergoing laparoscopic dismembered pyeloplasty and were immediately embedded in O.C.T. solution and flash-frozen in liquid nitrogen. Tissue sections (6 microm) were mounted on uncoated glass slides using a cryostat, fixed in 70% ethanol, stained with hematoxylin and eosin, and sequentially dehydrated in ethanol and xylene. Typically, paired samples of normal and hyperplastic urothelial cells were procured on separate caps from serial sections of each specimen by the Arcturus PixCell II LCM system using 3000 laser pulses and a spot diameter of 30 microm. Total proteins were harvested and quantitated. Differential expression profile analysis of 43 cytokines in normal and hyperplastic cells were performed using human protein chips. Briefly, the membranes were initially probed with protein (150 ng) from normal or hyperplastic cells and sequentially reacted with a cocktail of biotinylated cytokine antibodies and horseradish peroxidase-conjugated streptavidin. The membranes were developed using enhanced chemiluminescence and analyzed by densitometry. Comparative densitometric analysis revealed twofold to fourfold upregulation of growth-related oncogene alpha (GRO-alpha), interleukin (IL)-1alpha, interferon (INF)-gamma, IL-8, tumor necrosis factor (TNF)-alpha, RANTES, and macrophage inflammatory protein-1beta (MIP-1beta) and twofold to fourfold downregulation of transforming growth factor (TGF)-beta and IL-10 in hyperplastic urothelial cells compared with paired control cells. We here report the efficient application of LCM and proteomic array chips for expression profile analysis of cytokines in vivo. Because the etiology and pathogenesis of UPJO are still fragmentary, the marked heterogeneity of the observed cytokine alterations reported here may be of significance. Further studies are required to elucidate the functional significance of the differentially expressed cytokines in the pathogenesis of the disease.

Laparoscopic pyeloplasty for UPJ obstruction with crossing vessels: contrast-enhanced color Doppler findings and long-term outcome

Objectives. To evaluate, in the present long-term follow-up study, contrast-enhanced color Doppler imaging (CDI) findings and the clinical outcome of patients with crossing vessels at the obstructed ureteropelvic junction (UPJ), who underwent laparoscopic pyeloplasty. In a previous study, contrast-enhanced CDI proved capable of detecting crossing vessels at the UPJ. Methods. A total of 23 patients, who had undergone laparoscopic pyeloplasty and displacement of crossing vessels for UPJ obstruction at least 2 years before this study (mean 27 months), underwent contrast-enhanced CDI, intravenous urography, and renography. Contrast-enhanced CDI was performed using intravenously administered Levovist to assess the displacement of the vessels relative to the UPJ. All patients completed analog follow-up pain scales and quality-of-life assessment questionnaires. Results. Contrast-enhanced CDI revealed a cranial displacement (mean 1.3 cm) of the crossing vessels from the UPJ in all 23 cases. Intravenous urography showed a decrease in the degree of hydronephrosis, with a success rate of 100% in low-grade and 86% in high-grade hydronephrosis. The split renal function improved from 39.7% to 48.1%. Analog pain scale measurements demonstrated a mean improvement in pain of 92% (range 73% to 100%) and a mean quality-of-life score of 94 (range 78 to 100). Conclusions. Our series of patients with crossing vessels at the UPJ treated by laparoscopic pyeloplasty showed an excellent long-term successful outcome. Contrast-enhanced CDI allows for preoperative detection, as well as postoperative assessment, of the displacement of the crossing vessel. We recommend that the presence of a crossing vessel be routinely determined preoperatively, because it may influence the choice of treatment modality and thereby the clinical outcome.

Endopyelotomy failure is associated with reduced urinary transforming growth factor-beta1 levels in patients with upper urinary tract obstruction.

We previously demonstrated that obstructed ureteropelvic junction (UPJ) segments from patients who had secondary pyeloplasty after endopyelotomy failure expressed transforming growth factor-beta1 (TGF-beta1) at levels significantly lower than patients who had primary pyeloplasty. In order to determine whether these differences in secreted TGF-beta1 are detectable preoperatively in the urine, the TGF-beta1 concentration of urine from patients undergoing endopyelotomy was determined and compared with that from subjects without urologic disease. Bladder and renal pelvic urine from the obstructed side was obtained from patients (N = 34) undergoing primary endopyelotomy for UPJ obstruction. Bladder urine was also obtained from sex- and age-matched patients (N = 26) having no evidence of urinary tract obstruction. The TGF-beta1 concentration was determined by ELISA and normalized to the creatinine concentration. The bladder urine TGF-beta1 concentration was significantly (P < 0.02) higher in patients with UPJ obstruction (86.1+/-20.5 pg/mg of creatinine) than in those without obstruction (29.7+/-8.0 pg/mg creatinine). The TGF-beta1 concentration in the bladder urine of patients who underwent endopyelotomy and later returned because of UPJ obstruction (25.7+/-12.3 pg/mg of creatinine; N = 6) was not significantly different from the value in unobstructed patients but was significantly lower (P < 0.01) than in patients for whom endopyelotomy was successful (100+/-24.29 pg/mg of creatinine; N = 28). The renal pelvic urinary TGF-beta1 concentration was higher in patients for whom endopyelotomy was successful (772+/-490.1 pg/mg of creatinine) than in patients who underwent endopyelotomy and later returned because of UPJ obstruction (126.1+/-41.9 pg/mg of creatinine). These data suggest that preoperative concentration of TGF-beta1 in the bladder urine of patients with UPJ obstruction who fail endopyelotomy is not significantly different from that in subjects with no urologic disease and significantly lower than in those patients for whom endopyelotomy is successful. Thus, the preoperative bladder urine concentration of TGF-beta1 may assist in selecting patients for this operation, although further investigation is necessary.