Outcomes Of Pyeloplasty Research Articles

OUTCOME OF PEDIATRIC PYELOPLASTY IN RENAL UNITS WITH SPLIT RENAL FUNCTION LESS THAN 20

Background: Prenatally diagnosed, hydronehprosis does not mean presence of decompensated obstruction and spontaneously improvement or resolution can occur postnatally. If obstruction persists, the split renal function (SRF) of the diseased kidney will dramatically decrease, and surgical intervention will be necessary. Objective: Evaluation of outcome of pyeloplasty in children with ureteropelvic junction obstruction (UPJO) in renal unit with split function less than 20% and to asses renal function recoverability. Patients and Methods: Cohort (historical and concurrent) study included 88 patients with UPJO with split renal function (SRF) < 20%. Preoperative patient was investigated by abdominopelvic ultrasound, magnetic resonance urography (MRU) or computerized tomography and renal isotope scan. Split renal function and T 1/2 .Preoperative and postoperative were compared. Results of the procedure were evaluated by clinical examination, abdomino-pelvic ultrasound after one month. Urine analysis with culture and sensitivity and renal isotope scan after 6 months. Results: Our study included 88 patients divided into two groups according to SRF (group 1, SRF >20% and group 2, SRF < 20%). Mean preoperative SRF was 31.34 ± 15.27%in all cases, 41.79 ± 7.03% in group 1 and 13.06 ± 4.90% in group 2, which increased postoperatively to 38.35 ± 15.61%, 46.86 ± 8.43% and 20.81 ± 7.67% respectively and this improvement was highly significant. Group 2 included 9 patient with SRF < 10%, mean preoperative SRF was 6.21 ± 2.26% which increased preoperatively to 15.04 ± 7.09% , also in the remaining 23 cases, mean preoperative SRF was 15.74 ± 2.30% increased postoperatively to 23.07 ± 6.75% . Conclusion: Poorly functioning renal unit with SRF < 20%, can show functional improvement and recoverability, so in these renal units, we should not have to rush to nephrectomy and instead of that we can proceed to pyeloplasty.

Comparison of different pathological markers in predicting pyeloplasty outcomes in children

PurposeTo compare the efficacy of pathological markers like Interstitial cells of Cajal (ICC), neurons and Collagen to Muscle ratio (CM ratio), in predicting pyeloplasty outcomes. MethodsHistological sections from 31 patients with UPJO were analyzed for ICC & neurons on immuno-histochemistry and CM ratio on Masson's trichrome staining. Post-operative outcomes were analyzed at 1-year follow up; expressed as excellent, moderate or mild improvement, static and deterioration based on the three factors: ultrasound grade, differential renal function and renogram drainage pattern. The pathological findings were correlated with clinical outcomes. ResultsThe study group (n = 31) had a mean age 2.9 (0.6) years (M: F = 22:9). UPJ segment had significantly less ICC/neurons and more collagen compared to normal ureter (p = 0.001). Pathological parameters at the anastomosed end of ureter had a better correlation than those at UPJ with clinical outcome. CM ratio with a stronger correlation (r = − 0.94; p = 0.001) was a better predictor of prognosis than ICC (r = 0.76; p = 0.01) or neuron (r = 0.83; p = 0.01) density. ICC >10/HPF, neurons >6/HPF and CM ratio <1.2 at ureteric end anastomosed were predictors of success. ConclusionsCM ratio analysis at anastomosed ureter is a superior marker for predicting pyeloplasty outcomes. Level of EvidenceType 2: Development of diagnostic criteria in a consecutive series of patients.

A Rapid Special Staining Technique for Identification of Normal Ureter by Frozen Section in Children With Ureteropelvic Junction Obstruction.

The exact etiology of ureteropelvic junction obstruction (UPJO) is unknown, and inadequate excision of the narrow segment has been proposed as a cause of failure in 5% to 7% of cases of pyeloplasty. To study whether frozen section can be useful to detect normal ureter distal to UPJO during pyeloplasty. Histological sections from 31 patients with UPJO were analyzed for collagen to muscle ratio (CMR) on conventional (formalin) and rapid (frozen section) Masson's trichrome staining. Pathological findings were correlated with postoperative outcomes analyzed at 1-year follow-up and expressed as excellent, moderate, or mild improvement, static and deterioration based on ultrasound grade, differential renal function, and renogram drainage pattern. There was a very strong positive correlation (r = .94; P = .001) between CMR by conventional and rapid frozen Masson's trichrome staining. There was a very strong negative correlation between pyeloplasty outcomes and CMR on conventional staining (r = -.94; P = .001) or rapid frozen Masson's trichrome staining (r = -.91; P = .001). Regression analysis revealed that a CMR of 1.2 or less (95% confidence interval: 1.9-0.7) was associated with a successful outcome. It is feasible to intraoperatively identify normal ureter distal to UPJO using CMR analysis on the novel rapid frozen section technique reported.

A comparative study of outcome of pyeloplasty in stented and non-stented children

Background: It is a matter of debate whether to use a stent (double J) or not during pyeloplasty in patients of pelvic ureteric junction obstruction (PUJ obstruction). This study was conducted to assess which technique- stented or non-stented is better for paediatric patients with PUJ obstruction.Methods: 45 paediatric patients aged 0-12 years were included in this prospective comparative simple randomized sample study during the period of June 2015 to August 2017 in paediatric surgery division of department of surgery in M.Y. Hospital, Indore. All patients except one underwent open A-H dismembered pyeloplasty. The parameters used for comparison were renal parenchymal diameter, renal pelvis AP diameter, GFR (by DTPA scan) and rate of complications. Minimum follow up period was 3 months.Results: The M:F ratio was 2:1. Stented children had significant improvement in renal parenchymal diameter (i.e. increase) and GFR (of affected kidney) after pyeloplasty, whereas non-stented children too had improvement in renal parenchymal diameter and GFR (affected kidney) but was not significant. The percentage of postoperative complications were more in non-stented group as compared to stented group.Conclusions: In all paediatric cases with PUJO undergoing A-H pyeloplasty, both stenting and non-stenting have similar results and to place a double J stent should depend on choice of surgeon.

Early outcome of pediatric pyeloplasty in kidneys with split renal function less than 10%: A prospective study of 25 cases

ObjectivesTo detect the outcome of pyeloplasty in kidneys with split renal function (SRF) less than 10% in the pediatric age group. Subjects and methodsWe prospectively analyzed the data from 25 cases of ureteropelvic junction obstruction (UPJO) candidate for pyeloplasty with SRF less than 10%. Abdominopelvic ultrasonography and diuretic renogram using technetium-99m diethylenetriamine Penta acetic acid (DTPA) were done in all cases. We studied the improvement in pelvic anteroposterior diameter (APD) postoperatively. We compared pre and postoperative SRF after six months and one year. ResultsThe median age was 24 months (3 months–11 years), male to female 2:1. The median preoperative SRF was 5% (range: 0%–10%) and the median APD of the renal pelvis was 3cm (range: 2.2–5). There was significant improvement of median APD 0.8cm (range: 0.5–1.9) (P value <0.05). There was a significant postoperative improvement in the median SRF (P-value <0.05) as the median SRF after 6 months and 1year were 21% and 20%, respectively but there was no significant difference between SRF at six months and one year (P value 0.174). ConclusionPyeloplasty provides high rates of functional success even in very poorly functioning kidneys with SRF ≤10% by DTPA renogram in pediatric age group.

Nephroureterectomy versus pyeloplasty for giant hydronephrosis in children with upper urinary tract obstruction; perspectives from a tertiary health facility in Southern Nigeria

Background: Unrecognized or neglected cases of obstructed upper urinary tract in children can cause marked dilatation and structural damage to the ureters and kidney/s. In our region, many of such unrecognized obstructions result in giant hydronephrosis with resultant poor outcomes of pyeloplasty. We present our perspective of such giant hydronephrosis and make a case for straight nephroureterectomy rather than pyeloplasty which has been our standard treatment.Methods: This is a review of cases of congenital upper urinary tract obstruction with giant hydroureteronephrosis seen in children in our practice between March 2008 and February 2017. Case notes of patients who were managed within the period were retrieved to extract relevant data. Data obtained included the biodata, presenting features, dimension of renal pelvis and ureter at imaging and intraoperatively, treatment offered, outcome as at one-year follow-up. Results were subjected to simple statistical analysis.Results: There were 39 patients and they comprised 22 (56.4%) males and 17 (43.6%) females. Their age range was 3 to 14 years with a mean of 7 years. The most consistent clinical feature was abdominal distension. Five (12.8%) patients had abnormality of renal function preoperatively. The obstruction was unilateral in 30 (76.9%) cases and bilateral in 9 (23.1%) cases giving a total of 48 obstructions. All the patients were operated on. Complications encountered were mostly related to patients in whom we performed pyeloplasty. There were three mortalities related to sepsis and end stage renal disease.Conclusions: Upper urinary tract obstruction is often recognized late in our practice. Abdominal swelling is a common presenting feature of upper urinary tract obstruction in our practice. It appears that in unilateral cases, nephroureterectomy is a safer and more effective treatment option than pyeloplasty in such late cases with giant hydronephrosis. There is need for a well-designed prospective study to evaluate the option of nephroureterctomy in these cases.

Does the use of 5 mm instruments affect the outcomes of robot-assisted laparoscopic pyeloplasty in smaller working spaces? A comparative analysis of infants and older children

Pediatric robot-assisted laparoscopic (RAL) pyeloplasty has become a viable minimally invasive surgical option for ureteropelvic junction obstruction (UPJO) based on its efficacy and safety. However, RAL pyeloplasty in infants can be a challenging procedure because of the smaller working spaces. The use of the larger 8mm instruments for these patients instead of the 5mm instruments is common because of the shorter wrist lengths. We hypothesized that the use of 5mm instruments for RAL pyeloplasty in infants with smaller working spaces will have comparable perioperative parameters and surgical outcomes in comparison with older children with larger working spaces. We compared the perioperative parameters and surgical outcomes of RAL pyeloplasties performed by a single surgeon in infants and non-infant pediatric patients over a 2 year period. All of the procedures were performed using an 8.5mm camera and 5mm robotic instruments. Patient demographics, operative times, perioperative complications, hospital pain medication usage, hospital length of stay, and treatment success rates were compared between the two groups. A total of 65 pediatric RAL pyeloplasties were included in the study (16 infants and 49 non-infants, Table). There were no significant differences in gender, laterality, proportion of re-do pyeloplasty, or preoperative hydronephrosis grade between the two groups. All procedures were performed without conversion to open surgery or significant perioperative complications. There were no differences in segmental operative times (total operative time, console time, port placement time, time for dissection to UPJO, and anastomosis time), hospital pain medication usage, and hospital length of stay between the two groups (p>0.05 for all comparisons). The treatment success rates were 93.8% (15/16) and 100% (49/49), respectively (p=0.08). We present the first comparative study of infant and non-infant pediatric RAL pyeloplasty using 5mm robotic instruments. An advantage of the current study is the use of a single surgeon's experience to compare RAL pyeloplasty outcomes in infants with those of older children, a group in which RAL pyeloplasty has already been shown to be efficacious and safe. Operative tips for infant RAL pyeloplasty are also provided. RAL pyeloplasty is a safe and effective surgical modality even in infants, with comparable perioperative parameters and outcomes as those in older children. The use of 5mm instruments in infants does not affect outcomes and offers the potential for improved cosmesis.

Should micturating cystourethrogram be routinely performed for paediatric pyeloplasty patients?

Objective: Micturating cystourethrogram (MCUG) has traditionally been recommended as part of the preoperative evaluation of all cases of hydronephrosis. Several studies have shown that the majority of cases with pelviureteric junction obstruction (PUJO) and concomitant vesicoureteral reflux (VUR) were of low-grade and generally resolved spontaneously. We therefore retrospectively evaluated the need for routine MCUG in all cases of PUJO. Methods: We conducted a retrospective review of clinical records of all patients who underwent pyeloplasty in our institution between 2003 and 2015. Data collected included patient demographics, clinical presentation, radiological procedures performed, operative details as well as postoperative outcomes. Results: A total of 119 patients underwent pyeloplasty for PUJO during this study period. MCUG was performed in 88 patients (74%), of whom eight patients had VUR. All eight patients had unilateral PUJO and two patients had bilateral VUR. Only two patients had high-grade VUR (grade 4). These two patients also had hydroureter detected on ultrasound scan (US). All patients with VUR had spontaneous resolution of reflux. While comparing outcomes for patients with and without VUR, there was no statistically significant difference in terms of the need for redo surgery and improvement in differential renal function post-pyeloplasty. Conclusion: The outcome of pyeloplasty appears to be independent of the presence of concomitant VUR. Therefore, we conclude that MCUG does not need to be performed routinely for all PUJO patients. However, patients with history of recurrent urinary tract infection or findings of hydroureter on US should still be investigated with MCUG.

A Comparative Study of Outcome of Pyeloplasty in Stented and Non Stented Children with Puj Obstruction

Introduction: It is a matter of debate whether to use a stent (double J) or not during pyeloplasty in patients of puj obstruction. This study was conducted to assess which technique- stented or non-stented is better for paediatric patients with puj obstruction. Materials and method: 45 paediatric patients aged 0-12 years were included in this prospective comparative simple randomized sample study during the period of june 2015 to august 2017 in paediatric surgery division of department of surgery in M.Y. Hospital, Indore. The M:F ratio was 2:1. All patients except one underwent open A-H Dismembered Pyeloplasty. The parameters used for comparison were:- • Renal parenchymal diameter • Renal pelvis AP diameter • GFR (by DTPA scan) • Rate of complications. Minimum follow up period was 3 months. Result: Stented children had significant improvement in renal parenchymal diameter (i.e. increase) and GFR (of affected kidney) after pyeloplasty whereas non-stented children too had improvement in renal parenchymal diameter and GFR (affected kidney) but was not significant. The percentage of post-operative complications were more in non-stented group as compared to stented group. Conclusion: In all paediatric cases with pujo undergoing A-H pyeloplasty, a double J stent should be placed.

Immunohistochemistry in Ureteropelvic Junction Obstruction and Its Correlation to Postoperative Outcome.

Aim:To investigate the correlation between the status of interstitial cells of Cajal (ICC) in ureteropelvic junction (UPJ) and the resected ureteric margin and the postoperative outcome of Anderson-Hynes pyeloplasty in UPJ obstruction (UPJO) and to compare the ICC in the UPJ and the resected margin of the normal ureter.Materials and Methods:An observational study was conducted over a period of 2 years at the Department of Pediatric Surgery at Niloufer Institute of Women and Child Health. Children with intrinsic UPJO who underwent Anderson-Hynes dismembered pyeloplasty were included in the study. Six months postoperatively, the patients were divided into two groups based on diuretic isotopic renogram using technetium-99m-labeled diethylene triaminepentaacetic acid. Group 1 comprised patients with good surgical outcome. Group 2 comprised patients with a poor outcome. The histologic specimens were evaluated for ICC, and the immunohistochemical findings were correlated with the outcome.Results:Twenty-five patients were included in this study (19 male and 6 female). Seventy-six percent of patients were under the age of 1 year. Group 1 had 23 cases and Group 2 had 2 cases. Out of the two patients with a poor outcome, one had negative grading at the UPJ and one had positive grading. Both these patients had a negative grading at the lower resected margins. More number of patients (24%) had +++ grading at the lower resected margin when compared to the UPJ (8%).Conclusion:This is the first study which correlates the status of ICC in UPJ with the outcome of pyeloplasty in pediatric patients. Both the cases with bad outcome had no ICC at the lower margin of the resected specimen and one case had no ICC at the UPJ. There is a statistically significant difference (P = 0.001) in the number of ICC at the UPJ and the resected margin.

Functional and Morphological Outcomes of Pyeloplasty at Different Ages in Prenatally Diagnosed Society of Fetal Urology Grades 3-4 Ureteropelvic Junction Obstruction: Is It Safe to Wait?

To evaluate changes in functional and morphological outcomes in children with prenatally diagnosed Society of Fetal Urology (SFU) grades 3-4 ureteropelvic junction obstruction (UPJO) who underwent pyeloplasty at different ages. We also examined the effect of surgical wait time on recovery of renal function. All patients (aged 0-12 months) with prenatally diagnosed SFU grades 3-4 UPJO who underwent pyeloplasty in a single center between January 2013 and December 2015 were reviewed. One hundred thirty-three children were enrolled in this study. The children were divided into 2 groups according to their age at the time of surgery (group I: 0-3 months, group II: 3-12 months). We evaluated changes in parenchymal thickness, anteroposterior diameter (APD), and differential renal function (DRF) using ultrasound and diuretic renography. Functional and morphological outcomes were compared using Student t test. A total of 133 patients were included in the study. We found a significant difference in the change of DRF (difference between before and after pyeloplasty) between the 2 groups (P < .05). There were no significant differences in changes in parenchymal thickness and APD. Patients who waited 1-2 months had a significantly lower functional improvement compared with those who waited less than 1 month. Early surgery leads to a significant improvement in DRF. Wait times greater than 1 month can decrease functional improvement. For patients with prenatally diagnosed SFU grades 3-4 UPJO, early pyeloplasty is recommended in those with increasing renal pelvic APD and an obstructed renogram with differential renal function <40%.

Comparative Outcome Analysis of Children Who Underwent Pyeloplasty for Ureteropelvic Junction Obstruction Associated With or Without Supranormal Differential Renal Function

To compare pyeloplasty outcomes in children with and without "supra-normal" differential renal function (SNDRF) defined as >55% differential renal function (DRF) in children with ureteropelvic junction obstruction. Our prospectively collected pyeloplasty database (2008-2015) was reviewed (n = 151). A total of 140/151 (93%) patients had preoperative renograms and 26/140 (19%) were found to have SNDRF (DRF ≥ 55%). Of 151 patients, 51 (34%) had pre- and postoperative renograms allowing determination of change ≥5% in function. After excluding 2 patients with solitary kidneys, a total of 49 patients defined the study group. Of 49 patients, 12 had SNDRF and 37 did not. Baseline characteristics were similar including mean age at surgery (47.3 months vs 45.4 months) and time to surgery (8.7 months vs 9.8 months). Mean preoperative anteroposterior diameter was significantly different between groups (23.2 mm vs 31.0 mm; P = .04), but postoperative was similar (9.0 mm vs 12.1 mm; P = .14). Mean preoperative DRF was 60.2% in the SNDRF group vs 44.3% in the non-SNDRF. Mean postoperative DRF was 52.4% and 45.3%, respectively (P = .04). There were 9/12 (75%) SNDRF patients who experienced ≥5% loss in function compared to 2/37 (5%) in the non-SNDRF group (P < .01). Three-quarters of SNDRF patients demonstrated a decline of ≥5%DRF postoperatively when compared to non-SNDRF. This finding may not reflect true elevated renal function, but rather hyperfiltration in the setting of obstruction, which-if unrecognized as such-could result in postponing an otherwise beneficial surgical intervention.

Functional and morphological outcome after pyeloplasty for children with unilateral hydronephrosis

Objective To analyze the factors associated with the outcome of pyeloplasty in term of renal function and morphology improvement in children with unilateral ureteropelvic junction obstruction, in order to provide clinical evidence for the treatment of hydronephrosis in children. Methods Clinical data of 174 children who underwent unilateral dismembered pyeloplasty from January 2009 to June 2014 were retrospectively studied. Differential changes in renal function and renal morphology after pyeloplasty were assessed by serial renal scan and ultrasound. On the basis of preoperative split DRF, these patients were divided into three groups: group Ⅰ with DRF ≥40% (n = 99) , group Ⅱ with DRF 30%-40% ( n = 29) and group Ⅲwith DRF <30% (n = 46). According to their age at surgery, the children were divided into four groups, including group A aged 1-3 months (n = 52), group B aged 3 months- 3 years (n = 44), group C aged 3 - 6 years (n = 37), and group D aged more than 6 years (n = 41). Results In all 174 children, postoperative complication occurred in 7 cases, including urinary tract infection in 6 cases and renal atrophy in 1 case. A significant improvement of both function and morphology was confirmed in most patients (P<0.01). Patients in group Ⅰ showed stable renal function after operation(DRF 48.46%±4.80% vs. 50.78%±5.45%, P<0.01), of them who underwent pyeloplasty at 1-3 months of age showed the best obvious recovery of renal morphology. Renal function of patients in group II recovered obviously and most of them reached to the initial values (DRF 35.18%±2.95% vs. 43.91%±6.89%, P<0.01). While renal function of patients in group Ⅲ recovered significantly after surgery, most of them failed to restore the initial values(DRF 20.70%±6.90% vs. 33.78%±12.49%, P<0.01), and among them, the aged 1-3 months group possessed the best recovery. Moreover, the morphological improvement was similar to the functional improvement. The time for hydronephrosis recovered to less than Grade 2 of Society for Fetal Urology(SFU)was 6, 24 and over 24 months respectively in group I, Ⅱ and Ⅲ, and the renal morphology gradually improved with the increasing duration of follow-up. Conclusions The renal function and morphology of most patients improved significantly after pyeloplasty. Recovery of renal function and morphology after surgery was significantly correlated with the preoperative DRF. Early surgical intervention may improve the function and morphology recovery of the involved renal unit. Key words: Hydronephrosis; Ultrasonography; Renal dynamic imaging; retrospective study

Outcomes of Pyeloplasty in Very Poorly Functioning Kidneys: Examining the Myths

To assess the perioperative complications and functional midterm outcomes after pyeloplasty for poorly functioning kidneys due to ureteropelvic junction obstruction. We retrospectively analyzed patients who underwent pyeloplasty for primary ureteropelvic junction obstruction in very poorly functioning kidneys in terms of split renal function of ≤20% or estimated glomerular filteration rate of ≤20 mL/minute. Perioperative complications and postoperative outcomes in terms of symptomatic improvement and functional stabilization or recovery were assessed. A total of 32 patients with estimated glomerular filteration rate ≤20 mL/minute or split function ≤20% underwent pyeloplasty since January 2010. All patients were followed for a mean period of 26.8 months and none required reintervention for obstructive drainage, deteriorating function, or intractable pain. One patient had persistent pain requiring analgesics and overall success rate (defined as nonobstructive pattern, no deterioration in split function, and no persistent symptoms) was 93.7%. Thirteen patients (40.6%) showed significant improvement in renal function (>5% over preoperative), and in all except 1 (3.1%) case there was no further deterioration of function. Pyeloplasty provides high rates of morphological and functional success even in very poorly functioning renal units. There is a possibility of functional recovery in one-third of patients, and in most of the rest, there is no further deterioration.

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.

Time course of hydronephrotic changes following unilateral pyeloplasty

ObjectivesThe temporal pattern of hydronephrotic change following pyeloplasty has not been well defined. To address this issue, 23 years of postpyeloplasty follow-up data from a single surgeon were analyzed. Patients and methodsRecords of dismembered pyeloplasty from 1986 to 2004 were retrospectively reviewed. Ultrasound follow-ups were conducted at 3–6-month intervals after surgery for up to 3 years, and were then extended to either annually or biannually until the completion of puberty. Overall outcome of hydronephrosis (HN), timing of initial improvement and normalization were determined. Factors associated with these changes were examined. ResultsOf 215 patients who completed follow-up of at least 5 years, about 80% experienced either normalization or improvement. Once they had shown improvement of HN during follow-up, no recurrence was observed. The median time for recognition of initial improvement and normalization of HN was 8 months and 41 months after surgery, respectively. Multivariate analysis revealed that the presence of immediate postoperative obstruction was a negative factor for initial improvement. Symptomatic presentation and no initial improvement until 6 months after pyeloplasty turned out to be negative factors for normalization. ConclusionsThe results confirm the excellent long-term outcome of pyeloplasty, and highlight the importance of frequent ultrasound until initial improvement of HN, when subsequent ultrasound follow-ups may be safely omitted to focus on follow-up of renal function, proteinuria and hypertension.

Is Renal Biopsy a Better Predictor of the Outcome of Pyeloplasty in Adult Ureteropelvic Junction Obstruction?

To prospectively evaluate per operative renal biopsy as a predictor of outcome of pyeloplasty in cases of unilateral pelviureteric junction obstruction in adults. We conducted a prospective study on 24 patients with unilateral UPJ obstruction undergoing pyeloplasty between November 2005 and August 2006 and followed them until December 2010. Intraoperative renal wedge biopsy was obtained in these patients and this was correlated with preoperative DRF on diuretic renogram. Outcome of pyeloplasty was assessed at 1 and 3 years by diuretic renograms and the renal biopsy as a predictive tool was compared with preoperative DRF. Histology suggestive of obstructive damage to kidneys, such as significant glomerulosclerosis, widened Bowman's capsule, interstitial fibrosis, and tubular atrophy on renal biopsy was the highly significant predictor of poor outcome of pyeloplasty with a P value=.001 compared with preoperative DRF. Renal biopsy is better predictor of outcome of pyeloplasty compared with preoperative DRF in UPJ obstruction. In the presence of severe obstructive changes in renal biopsy, recoverability of renal function despite achievement of successful drainage is significantly decreased.

The Impact of Surgical Approach and Urinary Diversion on Patient Outcomes in Pediatric Pyeloplasty

Recent comparisons of the impact of the surgical approach on pediatric pyeloplasty outcomes have generally incorporated a form of internal ureteral drainage. We hypothesized that the surgical approach does not affect outcomes in children who undergo unstented pyeloplasty and stenting offers no long-term benefit in those with pediatric pyeloplasty. After receiving institutional review board approval we examined the records of all children who underwent initial pyeloplasty from December 2001 to December 2009. We compared unstented and stented pyeloplasties, and each surgical approach in the unstented group. During the study period 367 pyeloplasties were performed, including 231 unstented and 136 stented procedures. When comparing unstented to stented pyeloplasties, there was no difference in the complication or failure rate. Of unstented pyeloplasties 71, 67 and 93 were done using a transperitoneal laparoscopic approach, a flank approach and dorsal lumbotomy, respectively. There were 5 failures, of which 2 were laparoscopic, 2 used a flank approach and 1 used dorsal lumbotomy (p = 0.51). A total of 31 patients, including 10 treated with a laparoscopic approach, 3 with a flank approach and 18 with dorsal lumbotomy (p = 0.02), required second procedures, of which 24 were temporary drainage for a urine leak. Univariate analysis of factors associated with secondary procedures in the unstented pyeloplasty group showed that only surgical approach was significant (p = 0.05). In pediatric pyeloplasty there is no significant difference in outcome between stented and unstented repairs. In unstented repairs complications may vary by surgical approach. Regardless of the approach unstented pyeloplasty is safe and effective in the pediatric population.

Long-term results of pyeloplasty in poorly functioning kidneys in the pediatric age group

ObjectiveTo determine the efficacy and long-term outcome of pyeloplasty in poorly functioning kidneys in the pediatric age group. MethodRetrospective data analysis was performed on patients who underwent pyeloplasty in 2000–2008. The parameter analyzed was postoperative outcome. Success was defined on the basis of either improvement in symptoms or better drainage on postoperative Tc-99m DTPA renography done after 3 months and yearly thereafter. ResultsA total of 39 patients with a mean age of 8.6 years (4 months to 13 years), and male to female ratio of 3:1, with poor function on isotope renogram (<30%) were included in the study. Left to right side ratio was 1.3:1. Dismembered pyeloplasty was done in all patients. Laparoscopic pyeloplasty was done in 27 (66.7%) and open in 12 (33.3%) patients. Follow-up renograms were available for 35 patients: 31 showed improvement in drainage and no further deterioration in renal function and 4 showed an obstructed pattern; of these, two patients had significant deterioration in split function and the other two underwent redo pyeloplasty by open technique. At a mean follow up of 41.6 months (8–75), overall success rate was 90%. ConclusionPyeloplasty gives good intermediate-term results in poorly functioning kidneys in the pediatric age group.

Laparoscopic Pyeloplasty Outcomes of Elderly Patients

Laparoscopic pyeloplasty (LP) has been described as the new gold standard operation for patients with ureteropelvic junction obstruction (UPJO). As life expectancy continues to increase, we will be faced with the need to counsel older patients on the risks and benefits of undergoing surgery. It is clear that laparoscopic renal surgery has significant benefits over open renal surgery. Avoidance of open surgery would seem particularly beneficial in elderly patients who receive a diagnosis of this condition, although results in this group have not been formally studied. We compared the perioperative and medium-term outcomes of LP for primary UPJO in patients who are 70 years and older with those who are under age 70. Between January 2006 and June 2009, 74 consecutive patients underwent LP for UPJO performed by one surgeon. A four-port extraperitoneal approach was used in all but one case. Patient demographic and perioperative data were recorded prospectively. Outcome measures were success rate at a median follow-up of 12 months, complications, and length of hospital stay. Fifteen (20%) patients were aged 70 years or older. Older patients had a higher median American Society of Anesthesiologists score (2 vs 1). Moreover, older patients often presented with compromised renal function than their younger counterparts (median split renal function on the affected kidney 35% vs 45%, serum creatinine level 130 vs 90 μmol/L, P < 0.001). The success rate in the older group was 87%, with no treatment failures in the younger patients. Median hospital stay was longer for older patients (3 days vs 2 days, P = 0.01). Frequency of complications were not significantly different between the groups; however, there was a postoperative death in an elderly patient with a solitary kidney and preoperative renal failure. LP is feasible with generally good results for managing UPJO in patients 70 years or older. Older patients, however, are likely to need a longer hospital stay compared with their younger counterparts, and their co-morbidities should be carefully assessed preoperatively to minimize morbidity. Advanced chronologic age should not be a contraindication for LP in patients with symptomatic UPJO.