Primary Pelvi-ureteric Junction Obstruction Research Articles

Complications of open versus laparoscopic renal surgery among adult patients with primary pelvi-ureteric junction obstruction: What to expect?

Complications of open versus laparoscopic renal surgery among adult patients with primary pelvi-ureteric junction obstruction: What to expect?

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

Outcome of Open Pyeloplasty on Ipsilateral Renal Function

Objective: The objective of this study is to determine the ipsilateral renal function after open pyeloplasty. Patients and methods: The study comprises 50 patients with ultrasonographically and urographically demonstrated hydronephrosis and primary pelvi-ureteric junction obstruction for reconstructive surgical treatment at urology department of Bangabandhu Sheikh Mujib Medical University Hospital between January 2012 and September 2013. Anderson- Hynes pyeloplasties were performed in 50 patients. Data were collected by interview, review of records and documents in data collection sheet. Data were analyzed by using paired t-test. Level of significance was set at 5%(P<0.05). Statistical analysis done by SPSS (SPSS Inc. Chicago, IL, USA), version 16.0.0. Results: The male and female ratio was1: 0.33. Mean age of the patients was 7.35 years. Left and right side ratio was 1.5: 1. The mean ± SD of pre operative cortical thickness was 3.67 ± 0.91 and post operative thickness after 1 month, 3 months, 6 months and 12 months were 3.95 ± 0.91, 4.61 ± 1.18, 4.61 ± 1.18, 5.15 ± 1.31 and 6.22 ± 1.37 respectively. The mean ± SD of split renal function were 24.22 ± 3.42 and 29.14 ± 4.20 in pre operative and post operative respectively. The mean ± SD of split GFR were 25.38 ± 4.11and 34.47 ± 6.30 in pre operative and post operative respectively. Renal functional status was seen as improvement in 39, stable in 3, and deterioration in 2 patients. Conclusions: When dealing with patients with pelviureteric junction obstruction, surgical treatment should be undertaken in patients with symptoms and/or impaired renal function. Bangladesh Journal of Urology, Vol. 18, No. 1, Jan 2015 p.28-32

A modified suture technique for transperitoneal laparoscopic dismembered pyeloplasty of pelviureteric junction obstruction.

To describe a modified suture technique for transperitoneal laparoscopic dismembered pyeloplasty (TPLDP) that can be consistently replicated. Between June 2010 and April 2014, 21 men and 7 women with primary pelviureteric junction obstruction underwent our modified TPLDP suture technique performed by the same surgeon. In our method, the dismembering should be performed after performing half of anastomosis to achieve the maintenance of correct orientation and the prevention of torsion of anastomosis. We defined the success criteria as complete clinical resolution of flank pain for the patients with flank pain and complete radiologic resolution for the asymptomatic patients. The mean overall operative time for our technique was 137.3 minutes. The mean operative time for procedures on the left side was longer than on the right side (P = .02). The mean suture time was 37.2 minutes. The mean estimated blood loss was 29.4 mL, and the crossing vessel was found in 7 of 28 patients (25.0%). No open conversion was required. The mean follow-up time was 21.0 months. Only 1 patient still had frequent and intolerable flank pain after surgery whose treatment was unsuccessful. The rest of the patients got complete clinical or radiologic resolution. The success rate was 27 of 28 (96.4%). Our modified TPLDP suture technique is feasible and seems to be safe and to allow high success rate for the treatment of pelviureteric junction obstruction. Sizable sample and further analysis about technique will be completed in the future.

Stented versus nonstented open pyeloplasty for primary ureteropelvic junction obstruction in children

PurposeThe aim of the study was to compare the short-term results of stented versus nonstented open Anderson-Hynes dismembered pyeloplasty regarding operative time, hospital stay, functional outcome, and complications.Patients and methodsTwenty-seven pediatric open Anderson-Hynes dismembered pyeloplasties were performed for primary pelviureteric junction obstruction (PUJO) by a single team at a single institution from November 2009 to October 2012. Preoperative investigations included renal function tests, urine microscopy, culture, and sensitivity, renal ultrasonography, and diethylenetriamine pentaacetic acid (DTPA). Patients were simply randomized into two groups: group I, the stented group (either nephrostent or JJ stent), and group II, the nonstented group. Outcome was analyzed with respect to operative time, hospital stay, postoperative complications, postoperative effect on hydronephrosis, and postoperative differential renal function (DRF). Minimal follow-up was 6 months.ResultsThis study included 27 pediatric patients with primary PUJO, 14 patients in group I and 13 patients in group II. The mean age was 5.7΁2.6 years. Twelve (44.4%) cases were right sided and 15 (45.6%) were left sided; no bilateral cases were present. The mean DRF preoperatively was good in both groups (37.5% for group I vs. 35.6% in group II). There was no significant difference in operative time between both groups. The hospital stay was significantly shorter in the stented group, but this was mainly related to postoperative care policy in both groups. There was no significant difference between both groups regarding the complication rate. Postoperative DRF as well as hydronephrosis were significantly improved in both groups, but there was no statistically significant difference between both groups.ConclusionThe use of stents in pyeloplasty is not justified as a routine. The overall success and complication rates are independent of whether or not to drain or of the method of drainage. Therefore, it seems that the choice depends on local circumstances and surgeon preference. A larger number of patients is needed to validate these results.

The long-term results of laparoscopic retroperitoneal pyeloplasty in adults

ObjectivesTo report the long-term outcome of laparoscopic retroperitoneal pyeloplasty (LRP) in adults. Patients and methodsThirty patients underwent LRP for primary pelvi-ureteric junction obstruction (PUJO). Anderson–Hynes dismembered pyeloplasty was used in 28 patients and a Foley Y–V pyeloplasty in two. A JJ stent was inserted antegradely during the procedure. Patients were reviewed at 1month after LRP for stent removal, and then at 6 and 12months routinely, using excretory urography. ResultsThe mean patient age was 29.7years, with a female predominance of 60%. Conversion to open surgery was mandated by dense adhesions secondary to previous pyelonephritis in three patients, and difficulty in suturing in one. The mean (range) operative duration was 228 (190–280)min. There was a crossing vessel in 11 patients and it was not transposed in any. The mean hospital stay after LRP was 4.2days. The mean (range) follow-up was 60 (29–106)months. Of the 26 patients who had complete laparoscopic procedures, 23 had no evidence of obstruction on long-term postoperative intravenous urography and/or diuretic renography. ConclusionLRP combines the high functional success rate of open pyeloplasty in the long term and the minimally invasive morbidity of laparoscopy.

Laparoscopic management of primary pelvi-ureteric junction obstruction: Single-centre experience

ObjectiveTo evaluate the effect and safety of laparoscopic pyeloplasty in the treatment of pelvi-ureteric junction obstruction (PUJO). Patients and methodsIn 34 patients, laparoscopic dismembered pyeloplasty was used to treat primary PUJO. Information was obtained for symptoms, results of a nuclear scan before and after surgery, intraoperative blood loss, operative duration, stenting method, and hospital stay. Under general anaesthesia and in the flank position, a 10mm trocar was first placed above the umbilicus; three 5mm working ports were then placed. The ureter and pelvis were freed from surrounding adhesions. The obstructive pelvi-ureteric segment was then excised, and the opened point of the ureter spatulated. Ureteropyeloplasty between the lower pole, pelvis and spatulated ureter was made using a 4-0 polyglactin suture around a JJ stent. ResultsThe mean (SD) preoperative nuclear scan result was 23.6 (6.4)mL/min, with retention of tracer. The median operative duration was 200min, and the median blood loss 120mL. All patients were stented with a JJ stent. The mean hospital stay was 5 days. The final results were assessed at 6 months after surgery, when the mean (SD) nuclear scan result was 30 (7.4)mL/min. ConclusionLaparoscopic pyeloplasty is a safe and effective option which can produce satisfactory results both clinically and radiologically.

Role of Ureterocalicostomy in Children: A Follow Up Study

Purpose Dismembered pyeloplasty remains the main treatment for primary pelviureteric junction obstruction in childhood. However, ureterocalicostomy may be an alternative option in the presence of unfavourable anatomy or recurrent obstruction. Published data regarding ureterocalicostomy in paediatric patients is limited, with no large series reported since 1990. This study was undertaken to document and assess the outcome of ureterocalicostomy as both a primary and salvage procedure in a single centre series of 12 children managed over an 11 year period. Patients and Methods Seven girls and five boys underwent ureterocalicostomy under the care of two surgeons between 1997 and 2008. Median age at operation was 8 years (range 2 - 17). In 7 children primary ureterocalicostomy was performed for horseshoe kidney (3 cases) and gross hydronephrosis with unfavourable anatomy (4 cases). In 5 children salvage ureterocalicostomy was employed for recurrent PUJ obstruction post pyeloplasty. Indications, surgical technique and outcomes were assessed by retrospective analysis of case notes and imaging. Results Similar operative techniques and post operative drainage were employed by both surgeons with a mean operating time of 151 minutes (range 80 – 240). Hospitalisation averaged 5 days (range 3 - 7). No early complications were encountered. Mean follow up was 31 months (SD = 26.7). Successful outcomes were recorded in 10 children (92%) but one child (8%) developed symptomatic recurrent obstruction at 5 months which was successfully corrected by a further procedure. Conclusions We report the first paediatric case series of ureterocalicostomy since 1990. Our findings support the use of this procedure not only as a salvage technique for recurrent pelviureteric junction obstruction but also as an effective primary treatment for selected patients, particularly when associated with horseshoe systems.

Transperitoneal left laparoscopic pyeloplasty with transmesocolic access to the pelvi‐ureteric junction: technique description and results with a minimum follow‐up of 1 year

To describe and evaluate the safety and outcome of transperitoneal left laparoscopic pyeloplasty (TLLP) with a direct approach to the pelvi-ureteric junction (PUJ) through the mesentero-colic space, which avoids mobilization of the descending colon. From March 2005 to June 2006, 18 consecutive patients underwent TLLP with direct access. For each patient age, gender, body mass index (BMI), hospital stay, skin-to-skin operative time, time from incision of the posterior peritoneum to dissection of the PUJ, blood loss, time to resumption of oral intake and complications were recorded. Statistical analysis was used to assess whether the body habitus (BMI <25 kg/m(2) or >25 kg/m(2)) affected the outcomes. There were no complications during or after surgery and no conversions to open surgery were needed. The mean (SD) time to resumption of oral intake was 1.36 (0.5) days. The mean hospital stay was 3.3 (0.67) days and the mean follow-up was 17.4 (4.7) months. There was no statistical difference between patients with BMI higher or lower than 25 kg/m(2) (P = 0.42). The success rate at 1 year after surgery was 100%. TLLP with direct access to the PUJ through the mesentero-colic space is a safe and effective technique. This approach should be considered for all patients with left primary PUJ obstruction who are eligible for a LP and especially for slim patients or patients with a large renal pelvis.

Laparoscopic pyeloplasty

Laparoscopic dismembered pyeloplasty has become the "gold-standard" procedure for pelviureteric junction (PUJ) obstruction but consists of a steep learning curve especially via the retroperitoneal route. To examine the feasibility and safety of introducing this technique via the retroperitoneal approach to a laparoscopic naïve center. A retrospective data analysis of a single surgeon's (NEO) series from a large UK teaching hospital. The notes and imaging of all patients who underwent pyeloplasty for PUJ obstruction by NEO during a five-year period were reviewed. Parametric and nonparametric data are presented analyzed with Excel XP (Microsoft, Redmond, WA, USA). Our series consists of 67 patients. Three ports were used in 47/57 (82%), and the antegrade technique for stent insertion was utilized in 41/67 (61%). Median time to drink, eat, and mobilize was one day (range one to two), and to discharge three days (range three to four). Two patients required conversion to an open procedure, and two developed intraoperative complications. Postoperative complications at 30 (three major, seven minor) and 90 days (three major, three minor) are presented. With median follow-up of 15 months 61/65 (94%) patients were unobstructed, and 57/63 (90%) of patients were pain-free. Two patients re-obstructed requiring further surgery. Analysis of our series of patients illustrates that adopting a policy of retroperitoneal laparoscopic pyeloplasty for primary PUJ obstruction is feasible without compromising patient safety or functional results. There is no need to breach the peritoneum to facilitate the learning curve.

Robotic Anderson‐Hynes pyeloplasty: 5‐year experience of one centre

To present our 5-year experience with robotically assisted laparoscopic pyeloplasty (RALP), as LP has been shown to have similar success rates as open surgery, but standard LP requires high operative skills and a correspondingly long period of training, limiting its widespread availability, and RALP is easier and quicker to learn due to facilitated intracorporeal suturing. In all, 92 patients had transperitoneal RALP for pelvi-ureteric junction obstruction (PUJO) using the daVinci system (Intuitive Surgical, Sunnyvale, CA, USA). A transperitoneal dismembered Anderson-Hynes procedure was used in all cases. Three robotic ports and one assistant port were used in all cases while a JJ stent was left indwelling for 6 weeks. Both primary PUJO (including horseshoe kidneys in 80 cases) and secondary (in 12 cases) were considered eligible. The follow-up included ultrasonography, excretory urography and renal scintigraphy. The mean follow-up was 39.1 months; PUJO was successfully resolved in 89 patients (96.7%) while three required additional procedures. Haemorrhage into the collecting system and urine extravasation occurring early after surgery were the causes of failure. The mean (range) operative duration, including the set-up of the robot, was 108.34 (72-215) min; the mean duration of docking and surgery significantly decreased with experience (P < 0.001). The mean hospital stay was 4.57 days. Split renal function improved from 37.6% to 41.9%. No cases of secondary PUJO were recorded during extended follow-up. RALP using the daVinci system is safe and effective, achieving similar long-term success rates to open surgery. The three-dimensional versatility of the robot enables the surgeon to recapitulate the open procedure. The results were durable with no cases of late complications, corroborating the accuracy of robot-assisted intracorporeal suturing and the subsequent quality of the pelvi-ureteric anastomosis. Moreover, the robotic approach was easy and quick to learn for both the surgical and the technical staff. Therefore, RALP is our preferred technique to treat PUJO.

Magnetic resonance imaging in the evaluation of pelvi‐ureteric junction obstruction: an all‐in‐one approach

To study the ability of comprehensive magnetic resonance imaging (MRI) to replace multiple imaging methods in the evaluation of patients with pelvi-ureteric junction obstruction (PUJO). Between May 2003 and November 2005, 46 consecutive patients (22 male and 24 females; mean age 31.6 years) with symptomatic primary PUJO were included. All had comprehensive MRI, including MR urography (MRU), dynamic MRI and MR angiography (MRA). Morphological results of MRU were compared with that of renal ultrasonography or intravenous urography, while the anatomical results of MRA were compared with the operative findings. A correlation between MR clearance and radioisotope clearance was done using linear regression analysis. MRU showed the morphology of the collecting system in all patients, and the ureter below the PUJ in 31 of 46 (67%), but renal stones were missed in three of 10 patients. MRA showed crossing vessels in 22 patients (48%). There was a strong correlation between MR clearance and radioisotope clearance (r = 0.823, P < 0.001). From the MRI results, 35 patients (19 with crossing vessels and 16 with marked hydronephrosis) had pyeloplasty and 11 had an endopyelotomy. Findings during pyeloplasty showed one false-negative and one false-positive result of the preoperative MRI. Therefore, the sensitivity, specificity and accuracy of MRA were 95%, 94% and 94%, respectively. The outcome was successful in 44 (96%) patients. One failure after pyeloplasty was managed with endopyelotomy and the other was treated with pyeloplasty after endopyelotomy. Comprehensive MRI is a valuable and accurate single-imaging method for evaluating patients with PUJO.

Pelvi-ureteric junction obstruction treated with Acucise retrograde endopyelotomy.

To determine the efficacy of retrograde endopyelotomy for the treatment of pelvi-ureteric junction (PUJ) obstruction using the Acucise ureteric balloon cutting catheter. Between February 1995 and July 1997, 13 consecutive patients with primary PUJ obstruction underwent Acucise endopyelotomy at our institution. The mean follow-up was 17.7 months (range 7-33). The success of the procedure was based on objective patency on follow-up diuretic isotopic renography and the subjective resolution of symptoms. The treatment was successful by objective criteria in eight of 13 patients and by subjective criteria in nine. The mean operative duration was 33 min (range 25-45) and all 13 patients were discharged within 24 h of the procedure. There were no major complications, such as vascular injury requiring transfusion. There were no delayed failures, as all failures occurred within 3 months of the procedure. Of the four total failures, two patients have successfully undergone open pyeloplasty and one other was found to have a crossing vessel at the lower pole at the time of the operation. In this small series. Acucise endopyelotomy was a safe procedure that offered effective, expeditious first-line treatment for PUJ obstruction. All failures occurred soon after treatment and did not hinder subsequent open pyeloplasty. Further studies with additional patients and a longer follow-up are warranted to determine the long-term efficacy of this promising new treatment.

Antegrade endopyelotomy for pelvi-ureteric junction obstruction in children.

To compare the results of repairing pelvi-ureteric junction (PUJ) obstruction by percutaneous endopyelotomy in children with a similar series carried out in adults. Nine children with primary (six) or secondary (three) PUJ obstruction were treated using a one-stage cold-knife percutaneous endopyelotomy. The success and morbidity rates were compared with a series of 61 adults with primary (46) or secondary (15) PUJ obstruction treated similarly. In children, endopyelotomy was successful in five of six with primary and two of three with secondary PUJ obstruction, with a mean follow-up of 30 months (range 18-56). In the adults, endopyelotomy was successful in 38 of 46 (83%) with primary and 12 of 15 with secondary PUJ obstruction, an overall success rate of 82%, with a mean follow-up of 42 months (range 9-86). There was no statistical difference in the success rates with primary and secondary endopyelotomy between adults and children (P = 0.58). Failures were associated with high-grade hydronephrosis, a stenotic segment > 1.5 cm long and technical problems. Morbidity occurred in one of nine children and 3.2% of the adults. This early experience suggests that percutaneous endopyelotomy can be performed safely and successfully in children with primary PUJ obstruction. However, in secondary stenosis, the results were less than optimal. Larger series should be analysed to form definitive conclusions on the role of endopyelotomy for the treatment of PUJ obstruction in children, given the high rate of success of open pyeloplasty and its minimal morbidity.

Outcome of Secondary Open Surgical Procedure in Patients who Failed Primary Endopyelotomy

Endopyelotomy is an effective method for treating pelviureteric junction (PUJ) obstruction; however, up to 28% of patients fail endoscopic treatment and require a secondary open surgical procedure. Six patients underwent secondary open surgical procedures following failed endopyelotomy for primary PUJ obstruction at this institution. One patient had impaired renal function in the affected kidney prior to endopyelotomy and postoperative evaluation indicated further deterioration; nephrectomy was performed for chronic obstruction and pain. The remaining 5 patients underwent secondary open pyeloplasty. In 4 patients the operation was difficult and lengthy because of extensive periureteric fibrosis. Difficult dissection was associated with a repeat endoscopic attempt to repair the PUJ obstruction, urinoma formation or stent occlusion requiring intervention. A mean follow-up of 1.7 years demonstrated no radiographic or clinical evidence of recurrent obstruction in the 5 patients undergoing secondary open pyeloplasty; all 6 patients are currently asymptomatic.