Repair Of Ureteropelvic Junction Obstruction Research Articles

The Operative Management of Recurrent Ureteropelvic Junction Obstruction

Surgical repair of ureteropelvic junction obstruction is successful in 98% of cases. We evaluated children undergoing repeat pyeloplasty and discuss the etiology of recurrent ureteropelvic junction obstruction, surgical approach and outcome. Between 1982 and 1996, 366 children with ureteropelvic junction obstruction were surgically treated at our institution, including 16 who presented with recurrent ureteropelvic junction obstruction and required surgery. Repeat repair was successful in all 16 patients, including ureterocalicostomy in 3 and dismembered pyeloplasty in the remainder. No nephrectomy was necessary. Anteriorly elongated flank incisions were made in all cases. Dense scar tissue around and obstructing the ureteropelvic junction was noted in the majority of cases. In 7 patients a redundant pelvis resulted in a kink at the ureteropelvic junction. A nephrostomy tube was placed in all cases and an additional transanastomotic stent was used in all but 2. Obstruction was relieved with 1 operation. A redundant pelvis resulting in a kink at the ureteropelvic junction may contribute to a higher change of urinary leakage and subsequent obstructive scar formation in cases of failed pyeloplasty. Before repeat surgery anatomy should be precisely identified by antegrade and retrograde studies. The surgical approach usually involves identifying the ureter below the area of the previous surgery and then ensuring a tension-free anastomosis. If inadequate ureteral length or an intrarenal pelvis precludes direct anastomosis, ureterocalicostomy is an alternative. A nephrostomy tube and transanastomotic stent are advisable. Nephrectomy is rarely necessary and a good functional result can be anticipated.

Spiral CT angiography of the abdomen and pelvis: interventional applications.

Spiral CT angiography may be a useful adjunct for interventional radiologists in imaging vessels within the abdomen and pelvis. Specifically, the potential to assess abdominal aortic aneurysms preoperatively is within the realm of spiral CT angiography so long as scanners can quickly change collimation and table feed during the examination. The technique is also useful for imaging metal and nonmetal vascular grafts. The splanchnic arteries may be imaged in instances in which proximal vascular patency and course is questioned. The portal vein and its branches may be imaged prospectively with spiral CT angiography or retrospectively by postprocessing routine abdominal CT image data. The normal renal vasculature including accessory vessels may be imaged as part of preoperative evaluation for renal transplantation or for repair of ureteropelvic junction obstruction. Renal artery aneurysms may also be followed with spiral CT angiograms. Hemodynamically significant renal arterial stenoses may be detected with spiral CT angiography; grading the severity of those stenoses is within the realm of spiral CTA so long as careful attention is paid to technique.

In support of early surgical repair of ureteropelvic junction obstruction

Ureteropelvic junction (UPJ) obstruction is the most common urinary tract obstruction in children. Maternal ultrasonography has resulted in early diagnosis of an increasing number of neonatal cases, allowing repair of hydronephrotic kidneys before complications occur. We favor early treatment of congenital hydronephrosis, which should be performed prior to 6 months of age based on evidence of UPJ obstruction, increased pyelocaliceal dilatation, parenchymal thinning, contralateral normal kidney hypertrophy, and functional deterioration. One should not wait for evidence of progressive renal damage before making a diagnosis of obstruction. This therapeutic approach is supported by a review of the most relevant literature published on the subject and our clinical experience. None of the standard tests for measuring obstruction are ideal; hence, we recommend that the results of the different diagnostic procedures for UPJ obstruction should be examined collectively.

Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction

Objectives The aim of this study was to evaluate laparoscopic and retroperitoneoscopic pyeloplasty and to compare the efficacy of dismembered and nondismembered techniques. Methods Since May 1993, a modified laparoscopic transperitoneal (14 patients) and a retroperitoneoscopic approach (3 patients) have been used for the management of ureteropelvic junction obstruction. In 7 patients aberrant vessels were encountered; 1 patient had a horseshoe kidney. Surgical repair was achieved by dismembered pyeloplasty (8 patients), nondismembered Fenger-plasty (longitudinal incision, transverse closure; 3 patients), transection and reanastomosis of the renal pelvis (1 patient), ureterolysis and displacement of crossing vessels (4 patients). Results In 1 patient dismembered pyeloplasty could not be scheduled because of cardiovascular problems. A minimal transient lesion of the sympathetic nerve was observed postoperatively in 1 patient and pulmonary embolism in another. The operative time in dismembered pyeloplasty was between 240 and 360 minutes (mean, 280); the results were good in all patients. Equally good results were obtained with nondismembered Fenger-plasty, and the operating time was shorter (120 to 180 minutes). Ureterolysis was found to have a failure rate of 50%. Conclusions Laparoscopic dismembered pyeloplasty yielded good results, but it is too complicated to become a standard procedure. Nondismembered Fenger-plasty, which also showed good results, is more suitable for laparoscopy and retroperitoneoscopy. The indications for this technique should be defined more precisely as more experience is being collected. The results of ureterolysis when used as a single measure were poor, and, therefore, this technique should be abandoned.

Is routine stenting necessary in pyeloplasty?

Although the evaluation of surgical procedures for the repair of ureteropelvic junction obstruction continues, open pyeloplasty is still the gold standard in the management of pediatric cases. The use of stents in open pyeloplasty is subject to discussion among pediatric urologists. To clarify this question on the basis of our experience, we retrospectively reviewed our 28 stented and 15 unstented pediatric pyeloplasty operations in terms of hospital stay, early and late complications, and success rates. While there were no differences between both groups in terms of early and late complications and success rates, hospital stay favored the unstented cases. We have concluded that routine stenting in pyeloplasty is not necessary unless a perfect anastomosis is accomplished.

Nonintubated Anderson-Hynes Repair of Ureteropelvic Junction Obstruction in 60 Patients

We reviewed our experience with 68 consecutive Anderson-Hynes ureteropyeloplasties. The 64 infants, children and young adults ranged from 2 days to 28 years old (median age 2 years), and 28 were less than 1 year old. Intubation was used in only 4 patients: 2 who also underwent ureteral reimplantation for vesicoureteral reflux, 1 with stones in the renal pelvis and 1 with pyonephrosis. We successfully repaired 60 of 64 nonintubated renal units (93.4 per cent). Temporary postoperative ureteral stenting was required for extravasation from 8 renal units (12.5 per cent). Two patients later underwent repeat ureteropyeloplasty for recurrent obstruction. Nephrectomy was performed for pyonephrosis in 1 patient and for a nonfunctioning kidney that had exhibited poor function preoperatively in 1. Prolonged ileus necessitated extended hospitalization in 3 patients (4.6 per cent).We conclude that nonintubated dismembered ureteropyeloplasty for uncomplicated, primary ureteropelvic junction obstruction can be performed safely and successfully, and should be considered the standard treatment. Positioning of the Penrose drain is critical to avoid urinoma formation. When persistent urinary leakage occurs temporary diversion is easy and well tolerated. Hospital stay averaged 12.1 days for patients with extravasation compared to 4.3 days when no extravasation occurred. Immediate preoperative retrograde pyelography did not seem to contribute to postoperative urinary extravasation by causing edema of the ureteral orifice.

Endopyelotomy for Primary Repair of Ureteropelvic Junction Obstruction

A total of 12 patients underwent primary repair of ureteropelvic junction obstruction between November 1, 1985 and December 31, 1986. Ten patients underwent percutaneous incision of the ureteropelvic junction (endopyelotomy) as the initial effort to correct the obstruction. Two patients with ureteropelvic junction obstruction associated with an aberrant lower pole renal artery underwent dismembered pyeloplasty (Anderson-Hynes) via a flank incision.Of the 10 patients who underwent endopyelotomy 8 (80 per cent) have shown radiographic improvement. Radiographic stability of the obstructed ureteropelvic junction was demonstrated in the remaining 2 patients. No patient exhibited evidence of increased obstruction or decreased renal function. No patient required prolonged or rehospitalization for complications, and none required additional endoscopic or surgical procedures. All patients have remained clinically well after the initial release from the hospital.

Whitaker Test after Pyeloplasty: Establishment of Normal Ureteral Perfusion Pressures

Twenty-seven patients underwent percutaneous ureteral perfusion after successful surgical repair of ureteropelvic junction obstruction in order to determine the perfusion pressures in ureters without obstruction. In each patient, the postoperative ureteropelvic junction appeared widely patent and the rest of the ureter appeared entirely normal. Ureteral perfusion was performed via percutaneous puncture of the collecting system; the pressure in the pelvis was measured through this needle and bladder pressure was monitored through a urethral catheter. (renal pelvic) and (renal pelvic minus bladder) pressures were measured at 10, 15, and 20 ml/min perfusion rates. Absolute and differential pressures rose as the perfusion rates increased; absolute pressure rose but differential pressure fell as the bladder was filled. The upper limit of normal differential pressure encountered with the bladder empty was 13 cm of water during perfusion at 10 ml/min.

Management of Ureteropelvic Obstruction in the First Year of Life

From July 1971 until December 1978 we treated 19 male and 5 female children less than 1 year old for ureteropelvic junction obstruction. Diagnosis was based on high dose excretory urography with delayed films. Ultrasound was performed in some cases to confirm hydronephrosis. Cystoscopy and retrograde pyelography were not required. Of 32 obstructed kidneys 27 were repaired by dismembered reduction pyeloureteroplasty. Of 8 patients with bilateral involvement 3 underwent unilateral repair only because of lesser contralateral obstruction and 1 underwent unilateral nephrectomy. Of the 27 repairs 20 were protected by nephrostomy or pyelostomy drainage plus a small caliber silicone rubber or polyvinyl stent. Of the 6 non-stented repairs 2 had delayed opening of the repair. A frozen section renal biopsy aided in a decision to repair the kidney in 4 of 6 instances and in 10 other instances a renal biopsy was obtained for prognostic purposes. There were no secondary nephrectomies, although 2 boys required reoperations for a successful result. Instillation pyelography with fluoroscopic monitoring was used to determine when the tubes could be removed. Generally, we removed the stent 4 or 5 days postoperatively and the nephrostomy at a variable time after demonstration of patency of repair. In this group of small children pyelostomy or nephrostomy and intubation of the repair are useful additions to the surgical technique to prevent obstruction of the tiny and delicate infant ureter by anastomotic edema or kinking of the repair.